Summary
Already effective May 1, 2025: Pennsylvania's Medical Assistance fee-for-service program accepts the 2024 ADA Claim Form for dental prior authorization requests, claims, and claim adjustments. The 2019 ADA Claim Form could be used through October 31, 2025, and from November 1, 2025 the Department no longer accepts it; 2019 forms received on or after that date are returned with a request to submit the 2024 form. The 2024 form adds fields for Payer ID (box 3a), Other Payer ID (box 11a), Date Last SRP (box 39a), and Locum Tenens Treating Dentist (box 53a).
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What to do
Action · 9 steps
01Already effective May 1, 2025: Billing team should use the 2024 ADA Claim Form for dental prior authorization requests, claims, and claim adjustments submitted to the fee-for-service program.
02Order the form from the American Dental Association at 1-800-947-4746 or at ada.org, since it is not available on the MA 300X order form, and use original forms only, because laser and dot matrix produced forms are returned.
03Complete box 3a (Payer ID), box 11a (Other Payer ID), box 39a (Date Last SRP) and box 53a (Locum Tenens Treating Dentist) as applicable; the completion aid lists these items as optional for MA.
04For prior authorization of listed services, such as crowns, surgical extractions, periodontal services, endodontics, complete and partial dentures, and orthodontics, submit the 2024 form with a full mouth periapical or panorex and current radiographs to Department of Human Services, Office of Medical Assistance Programs, P.O.
05Box 8050, Harrisburg, PA 17105-8187.
06For a dental benefit limit exception, attach the Dental BLE Request Form (MA 549), write "Dental BLE Attached" in Box 35, and enter the BLE authorization number in the appropriate claim field.
07Services provided beyond a recipient's benefit limits are not covered unless a BLE is requested and approved.
08Claims submitted on a 2019 form received on or after November 1, 2025 are returned for resubmission on the 2024 form.
09Confirm current applicability of this form version on the Department's website before billing, since the 2019 form was accepted only through October 31, 2025.
Codes mentioned
D2710D2721D2740D2751D2791D7220D7230D7240D7250D4210D4341D4355D4910D7280D5110D5120D5130D5140D5211D5212D5213D5214D7283D8080D8210D8220D8670D8680
Original notice
MAB2025051301
pa.gov · Always check the source before changing claims.
Related changes
See all Pennsylvania Medicaid (DHS) changes →mab2025091101HighEffective Aug 1, 2025 · Provider BulletinMAB2023040401MediumEffective Apr 4, 2023 · Provider BulletinMedical Assistance Program Dental Fee Schedule and Dental Provider Handbook Update MAB 27-19-17MediumEffective Aug 19, 2019 · ReimbursementMAB2023083101MediumEffective Sep 5, 2023 · Provider BulletinBrowse every Pennsylvania Medicaid (DHS) change in the policy list
Related policy hubs
Pennsylvania Medicaid (DHS) policiesPA policy changesDentistryCode D2710Code D2721Code D2740Code D2751Code D2791Code D7220Code D7230Code D7240Code D7250Code D4210Code D4341Code D4355Code D4910Code D7280Code D5110Code D5120Code D5130Code D5140Code D5211Code D5212Code D5213Code D5214Code D7283Code D8080Code D8210Code D8220Code D8670Code D8680