Get Ada J430d 2012-2025

The ADA J430D is an essential document for submitting dental claims to insurance providers. This guide provides clear, step-by-step instructions to help you complete the form efficiently and accurately.

Follow the steps to fill out the ADA J430D online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the header information. Identify the type of transaction being submitted by marking the appropriate box—for example, select 'Statement of Actual Services' if services were performed, or 'Request for Predetermination/Preauthorization' if applicable.
3. Enter the predetermination/preauthorization number if you have one. This number must be provided by the insurance company for pre-authorized claims.
4. In the Insurance Company/Dental Benefit Plan Information section, fill in the company name, address, city, state, and zip code of the insurance provider. Ensure this is the primary plan if multiple plans exist.
5. Answer the 'Other Coverage' question. If the patient has additional dental or medical insurance, mark the appropriate boxes and fill items 5 through 11 regarding the other coverage.
6. Complete the Policyholder/Subscriber Information section by entering the details of the insured person, including their name, address, date of birth, and identifier.
7. Fill out the Patient Information section, which includes the patient's relationship to the policyholder, name, date of birth, and gender.
8. Document the Record of Services Provided. For each dental procedure performed, enter the procedure date, area of the oral cavity, tooth numbering, procedure code, description of services, and total fee.
9. Complete any additional sections relevant to your claim, such as authorizations, billing dentist information, and treating dentist details.
10. After filling in all sections, review the form for completeness and accuracy, then save your changes. You can download, print, or share the completed form as needed.

Ensure your claims are submitted correctly by filling out the ADA J430D online today!