Get Ada J-400 2012-2025
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How to fill out the ADA J-400 online
The ADA J-400 form is essential for submitting dental claims to Regence. This guide provides a straightforward, step-by-step approach to ensure that you complete the form accurately and efficiently.
Follow the steps to fill out the ADA J-400 claim form online.
- Click ‘Get Form’ button to obtain the ADA J-400 claim form and open it for editing.
- Identify the type of transaction by checking the appropriate box corresponding to your claim under section 1.
- If applicable, enter the predetermination or preauthorization number provided by your insurance company in section 2.
- In section 3, fill out the insurance company’s name, address, city, state, and zip code.
- Check the applicable box for other dental or medical coverage in section 4, if you have it.
- If section 4 is applicable, enter the name of the policyholder/subscriber in section 5 along with their date of birth in section 6.
- Indicate the gender of the policyholder in section 7 and provide their policyholder/subscriber ID in section 8.
- Include the group number for the policyholder's other coverage in section 9 and their relationship to the patient in section 10.
- In section 11, supply the other insurance company's name and address if applicable.
- For the patient's information, start with entering their name and address in section 20, followed by their date of birth and gender in sections 21 and 22.
- Complete the record of services provided by detailing the procedure date in section 24, area of oral cavity in section 25, and including the necessary procedure codes in sections 29 and 30.
- Finalize the claim by signing and dating the form in section 53. Ensure that all required fields are filled accurately before submission.
- Once all sections have been completed, you can save changes, download, print, or share the completed form as needed.
Complete your ADA J-400 claim form online today to ensure timely processing of your dental claims.
Box 25 on a dental claim form is designated for the reporting of the National Provider Identifier (NPI) number for the service provider. Including the NPI is crucial for correct processing of your claim, as it ensures that the insurance company identifies the healthcare provider accurately. When using the ADA J-400 form, make sure that this section is filled out properly to facilitate smoother claims processing. Proper use of the claim form can save time and reduce potential issues.
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