МАН·Мх Dental Claim Form

The МАН·Мх Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. МАН·Мх policy promotes use and acceptance of the most current version of the МАН·Мх Dental Claim Form by dentists and payers.

The following materials are prepared by МАН·Мх Practice Institute staff with contributions from the МАН·Мх Council on Dental Benefit Programs and other internal and external knowledge experts.

МАН·Мх Sample Dental Claim Form and Completion Instructions

Download the current version of the 2024 МАН·Мх Dental Claim Form © (PDF)
Download the Comprehensive МАН·Мх Dental Claim Form Completion Instructions (PDF) for all items (#’s 1 through 58)
Special Completion Instructions – Reporting Ordering, Referring, and Prescribing Providers (PDF)
Download the Special Completion Instructions for Medicare Administrative Modifiers © (PDF)

Completion Instructions Supplement 1 вЂ“ Reporting Oral Cavity, Tooth Numbers or Tooth Surfaces

This "МАН·Мх Guide to Dental Procedures Reported with Area of the Oral Cavity or Tooth Anatomy (or Both)" Completion Instructions Supplement 1 concerns claim form item #s 25, 27, and 28. It specifies, by CDT code, when Area of the Oral Cavity, Tooth Numbers or Tooth Surfaces should be reported.

Completion Instructions Supplement 2 вЂ“ Guide to Reporting D9985

These instructions concern claim form items # 24 through 32 and are applicable only when reporting procedure code вЂњD9985 sales tax.вЂќ

Special Completion Instructions for D9985

Completion Instructions Supplement 3 вЂ“ Universal Tooth Designation System ValueSet

The universal tooth designation or numbering system is accepted and approved by the МАН·Мх and is the most commonly used system used by dental professionals in America. This valueset includes the codes which should be used on the МАН·Мх Dental Claim Form as defined in the Completion Instructions. The associated International Organization for Standardization (ISO) designation system for teeth (ISO/3950) is included to assist with mapping and should not be used on the МАН·Мх Claim Form.

Universal Tooth Designation System ValueSet

Technical questions concerning the МАН·Мх Dental Claim Form's content or completion should be directed to the МАН·Мх's Practice Institute staff via email (dentalcode@ada.org). You can also reach out to us from 8:00 a.m. to 5 p.m. Central time, Monday through Friday by phone 800.621.8099. The МАН·Мх Dental Claim Form and the CDT manual are copyrighted documents. Reproduction of copyrighted information is subject to a licensing agreement.

For information about licensing of the МАН·Мх Dental Claim Form, please see CDT.
For any questions regarding pricing or purchasing copies of the МАН·Мх Dental Claim Form, including one that may be individually completed or printed. please visit the or call 800.947.4746.