This article walks you through each field of the ADA 2012 and 2019 Forms, and how each field is populated.
Click the link below for the ADA 2024 form:
If you’re looking for the CMS Form at a Glance article, check this article here:
CMS 1500 (02/12) Form At A Glance
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ADA Box 1 - Type of Transaction
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MacPractice will also put an X in the Predetermination/Preauthorization box when a Predetermination is printed for the patient. A predetermination is printed from the Treatment the Treatment Plan in the Ledger screen. Select the treatment charges and then from the Print pop-up menu select the Print Predetermination.
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ADA Box 2 - Predetermination/Preauthorization
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Information will be populated on the claim when an insurance requires a Prior Authorization number. It is pulled from the the Prior Authorization number entered and insurance pop-up menu selected on the Prior the Prior Auth tab of the Incident. There must be at least 1 remaining visit left for this to pull onto the claim.
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The prior authorization number must also be selected in the insurance claim creation window from the Prior Auth pop-up menu.
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ADA Box 3 - Company/Plan Name, Address, City, State, Zip Code
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This box will be blank if there is no secondary insurance. Information is populated by the Subscriber ID field on the associated insurance on the patient's Insurance tab in the Patient screen.
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This field lists the guarantor's name and address listed in the Primary or Secondary screen (Note: Name includes only First, Middle and Last name fields).
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ADA Box 13 - Subscriber Birth Date
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Information is pulled from the Subscriber ID field for the associated insurance on the patient's Insurance tab in the Patient screen.
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ADA Box 16 - Plan/Group Number
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Information is pulled from the Employer information selected in the Employer pop-up menu for the guarantor associated to the primary insurance.
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ADA Box 18 - Relationship to Subscriber
This field pulls from the patient's Relationship to Primary and Secondary pop-up menu in the Patient screen.
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ADA Box 19 - Reserved For Future Use
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Selecting Unknown in the Sex pop-up menu will leave this field unchecked.
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ADA Box 23 - Patient ID
This information comes from the Patient ID that is automatically assigned to each patient in MacPractice. You can see this information in the sidebar’s “Patient ID” column with a patient selected, or in the MacPractice window header.
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You can enter up to five of the surface codes without any spaces.
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ADA Box 29 - Procedure Code
This box pulls from the Code field in the charge window.
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ADA Box 29a - Diagnosis Pointer
The designator of A, B, C, or D are reflected in Box 34a from in Box 34a from the ADA 2012 form.
ADA Box 29b - Quantity
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The Diagnosis Codes will generate a letter corresponding to one of the four codes (A-D) that will appear in Box in Box 29a.
ADA Box 35 - Remarks
This box populates from the Notes tab in the charge window.
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Information is pulled from Box 39 Number of Enclosures fields for Radiograph(s), Oral Image(s) and Model(s), found under the Claims tab of the Incident.
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Note: This Claims view is visible on MacPractice DDS by default. If you are on MacPractice MD, DC, or 20/20, you may need to check "Display both CMS and ADA Claim view" in Preferences > Ledger > Incident Tab. |
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This information can only be changed or updated by MacPractice.
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Note: If there is an alternate name entered into a field in the Provider's User reference, located in Users > Providers Tab > "Name on Line 1 of ADA Box 48 (optional)", that information will pull into Line 1 instead of the Office Name. |
ADA Box 49 - Billing NPI
This field can pull from several different locations:
If the office is billing as a group, the information will pull from the Group National Provider ID (NPI) field in the Office Reference.
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The Group NPI information can be overridden from the Group National Provider ID (NPI) field under the Claim Credentials tab inside the Provider tab within the User Reference.
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If the "Bill as Individual" box is checked under the Provider IDs tab of the Insurance Company Reference, this information will pull from the National Provider ID (NPI) field under the Claim Credentials tab inside the Provider tab within the User Reference.
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ADA Box 50 - Billing License
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Number
This information is populated from the State License field under the Claim Credentials tab inside the Provider tab of the User Reference for the provider.
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ADA Box 51 - SSN or
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TIN
This field pulls from the information entered in the Federal or SSN field found under the Provider Numbers tab of the User Reference.
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The box will have the SSN or TIN number entered, depending on what is selected from the "Provider Tax ID on Claims" pop-up menu found under the Claim Credentials tab inside the Provider tab of the User Reference for the provider.
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This box also populates from the Legacy Type Override pop-up menu under the Provider IDs tab of the Insurance Company Reference.
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ADA Box 52 - Office Phone
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Number
Information is populated from the Phone field in the Office Reference.
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ADA Box 52a - Additional Provider
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ID
Information is pulled from the Provider field under the Provider Numbers tab of the provider's User Reference.
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ADA Box 53 - Treating
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Dentist
This field pulls from the Name Printed in Box 53 of Insurance field under the Provider tab of the User Reference for the provider.
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ADA Box 54 - Treating Dentist
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NPI
Information is populated from the National Provider ID (NPI) field under the Claim Credentials tab inside the Provider tab of User Reference for the provider.
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ADA Box 55 - Treating Dentist License
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Number
This information is populated from the State License field under the Claim Credentials tab inside the Provider tab in the User Reference for the provider.
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ADA Box 56 - Treatment Location
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Address
This field can pull from several different locations: The Office address will pull into this field from the Office Reference if there is not a facility entered in the charge window or a default facility selected in the Office Reference.
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If there is a facility in the charge window, the selected facility's address will be printed from the Facility Reference.
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If there is a default facility entered in the Office Reference, this will override the office address, and the default facility's address will be printed on the claim from the Facility Reference.
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ADA Box 56a - Treatment Provider Specialty
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Code
This box pulls information from the Provider Taxonomy (Specialty Code) field under the Provider tab > Claim Credentials tab in the User Reference for the provider.
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ADA Box 57 - Phone
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Number
Information is populated from the Phone field under the User Information tab of the User Reference for the provider.
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ADA Box 58 - Additional Treatment Provider
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ID
Information pulls into this box from the Paper ID field under the Provider IDs tab of the Insurance Company Reference.
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