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:
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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. |
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