Items 5 – 11 Comprehensive ADA Dental Claim Form completion instructions Any updates to these instructions will be posted on the ADA’s web site (). Harvard Pilgrim Health Care—Provider Manual. F October Billing and ReimBuRsement—ResouRces. Completing a Paper ADA J Form. Block. In order to report the National Provider Identifier (NPI), the American Dental Association (ADA) has revised the ADA Dental Claim Form (version J).
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ADA Dental Claim Form
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Indicate this policyholder or subscriber’s gender with a check mark in box SAM Broadcaster Cloud In box 3, enter your dental benefit plan or insurance company name, address, city, state and zip code.
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ADA Dental Claim Form
In box 9, enter the plan or group number. In box 4, indicate whether you have other dental or medical coverage with a check mark.
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