MedicaidAdministrativeMedium impact
MAB2023040401
Pennsylvania Medicaid (DHS)·PA · Dentistry, Oral & Maxillofacial Surgery·Provider Bulletin
Effective date
Apr 4, 2023
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is transitioning from the 2012 ADA Claim Form to the 2019 ADA Claim Form for dental providers. Both forms are accepted until May 31, 2023, but starting June 1, 2023, only the 2019 version will be accepted and claims submitted on the old form will be returned.
Action Required
By May 31, 2023: Dental billing team must transition to using the 2019 ADA Claim Form for all Pennsylvania Medicaid claims. Order new forms from ADA at 1-800-947-4746 or catalog.ada.org. Update billing procedures to use new gender field options in boxes 7, 14, and 22, and updated text in boxes 8 and 15. Remove ICD-9 codes from box 34 (use ICD-10 only). Claims submitted on 2012 forms after June 1, 2023 will be returned for resubmission.