TO: Dental Providers
June 1, 2017, Alabama Medicaid will only accept the 2012 ADA Dental Claim Form
when a paper claim is required in order to process the claim. Claims received after June 1, 2017 on any
other claim form will be returned without being processed.
What is changing on the 2012 ADA
Dental Claim Form?
ADA Dental Claim Form allows providers to enter up to 4 diagnosis codes.
However, diagnosis codes are NOT required to be present on the claim form.
sample 2012 ADA Dental Claim Form and instructions for completing the form can
be found in Chapter 5 of the provider billing manual (April 2017 edition). Provider manuals are available for viewing
online at the Medicaid website:
How do I obtain the 2012 ADA Dental
may obtain the claim forms from a printer of their choice. HPE does not supply
How should I prepare for this change?
should notify their software vendor that Medicaid will require the 2012 ADA
Dental Claim Form beginning on June 1, 2017. Some vendor changes may be
required to ensure you can properly print the claim form.
As a reminder, all claims which do not require attachments or an
Administrative Review override by Medicaid must be submitted electronically.
Questions should be directed to the
Provider Assistance Center at 1-800-688-7989.
The Current Procedural Terminology
(CPT) and Current Dental Terminology (CDT) codes descriptors, and other data
are copyright © 2017 American Medical Association and © 2017
American Dental Association (or such other date publication of CPT and CDT).
All rights reserved. Applicable FARS/DFARS apply.