2012 ADA Dental Claim Form Required as of July 1, 2015

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Please Note: As of July 1, 2015, claims received on an older version of the form for any dental services payable under a member’s dental or medical benefit plans will be returned to the submitting dental provider with a request to resubmit the services on the current 2012 claim form.

At Blue Cross and Blue Shield of North Carolina (Blue Cross NC) we recognize the most current claim form versions to be the most appropriate for reporting services provided to our members. Dental services should be reported on the ADA American Dental Association® claim form (version 2012), and medical services by use of the Centers for Medicare and Medicaid Services, CMS HCFA-1500 claim form (version 2012).

Blue Cross NC accepts claims filed both on paper and via electronic format. Claims filed electronically (EDI [electronic data interchange]) are the most efficient, and Emdeon clearing house should be utilized for dental EDI submissions.

When deciding which claim type to file, dental or medical, some general guidelines apply:

  • Preventive, basic or major dental care services are typically covered under a member’s Blue Cross NC dental benefit, and these services must be filed using the 2012 version of the ADA claim form. Services such as pediatric oral health benefits and medically necessary orthodontia, which are considered part of the patient’s medical coverage under an Affordable Care Act (ACA) metallic plan, should also be filed on the 2012 version of the ADA claim form.

  • Medically necessary services are typically covered under a member’s Blue Cross NC medical benefit, and these should only be filed on the CMS HCFA-1500 (version 2012) claim form. Medically necessary services typically include oral surgery involving bones or joints of the jaw; dental treatment related to conditions of accidental injury of sound teeth, jaw, cheeks, lips, tongue, roof and floor of the mouth; congenital deformity, including cleft lip and cleft palate; removal of tumors or cysts, which are not related to teeth or associated dental procedures; and tumors or cysts exostoses for reasons other than for the preparation of the oral cavity for delivery of dentures.

This change aligns us and our dental providers with the Worlds Health Organization ICD-10 compliance date of October 1, 2015. Additional information about how to file dental claims is available online for your reference in the Blue BookSM dental e-Manual.