Effective April 4, 2023, the Pennsylvania Department of Human Services accepts the 2019 ADA Claim Form for dental prior authorization requests, claims and claim adjustments for fee-for-service Medical Assistance beneficiaries. Providers could continue using the 2012 ADA Claim Form through May 31, 2023, and from June 1, 2023 the Department no longer accepts it and returns 2012 forms with a request to complete and submit the 2019 form. The 2019 form updates Boxes 7, 14 and 22 to reflect three gender options, relabels Boxes 8 and 15 as Policyholder/Subscriber ID (Assigned by Plan), and removes ICD-9 from Box 34 because it is no longer a valid diagnosis code set.
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01Already effective June 1, 2023: The billing team submits dental prior authorization requests, claims and claim adjustments for fee-for-service beneficiaries on the ADA Claim Form Version 2019, because the Department no longer accepts the 2012 form and returns 2012 forms with a request to complete and submit the 2019 form.
02Complete Boxes 7, 14 and 22 using the updated gender options, note that Boxes 8 and 15 are labeled Policyholder/Subscriber ID (Assigned by Plan), and note that Box 34 no longer includes ICD-9.
03Order the 2019 form from the American Dental Association by calling 1-800-947-4746 or at catalog.ada.org, and use the PA PROMISe Provider Handbook 837 Dental/ADA Version 2019 for detailed completion instructions.
04Check current applicability of this bulletin before acting on it, and direct questions to the Provider Service Center at 1-800-537-8862.
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