ADA 2012 and 2019 Form At A Glance
- Dylan Nigh
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
- 1 ADA Box 1 - Type of Transaction
- 2 ADA Box 2 - Predetermination/Preauthorization
- 3 ADA Box 3 - Company/Plan Name, Address, City, State, Zip Code
- 4 ADA Box 4 - Other Insurance Coverage
- 5 ADA Box 5 - Other Coverage Subscribers Name
- 6 ADA Box 6 - Other Coverage Subscriber's Date of Birth
- 7 ADA Box 7 - Other Coverage Subscriber's Gender
- 8 ADA Box 8 - Other Coverage Subscriber's ID
- 9 ADA Box 9 - Other Coverage Subscriber's Group Number
- 10 ADA Box 10 - Patient Relationship to Insured
- 11 ADA Box 11 - Other Insurance Name and Address
- 12 ADA Box 12 - Subscriber Information
- 13 ADA Box 13 - Subscriber Birth Date
- 14 ADA Box 14 - Subscriber Gender
- 15 ADA Box 15 - Subscriber ID
- 16 ADA Box 16 - Plan/Group Number
- 17 ADA Box 17 - Employer Name
- 18 ADA Box 18 - Relationship to Subscriber
- 19 ADA Box 19 - Reserved For Future Use
- 20 ADA Box 20 - Patient Name and Address
- 21 ADA Box 21 - Patient Birth Date
- 22 ADA Box 22 - Patient Gender
- 23 ADA Box 23 - Patient ID
- 24 ADA Box 24 - Procedure Date
- 25 ADA Box 25 - Area of Oral Cavity
- 26 ADA Box 26 - Tooth System
- 27 ADA Box 27 - Tooth Number/Letter
- 28 ADA Box 28 - Tooth Surface
- 29 ADA Box 29 - Procedure Code
- 30 ADA Box 29a - Diagnosis Pointer
- 31 ADA Box 29b - Quantity
- 32 ADA Box 30 - Procedure Description
- 33 ADA Box 31 - Fee Amount
- 34 ADA Box 31a. - Other Fee(s)
- 35 ADA Box 32 - Total Fee Amount
- 36 ADA Box 33 - Missing Teeth
- 37 ADA Box 34 - Diagnosis Code List Qualifier
- 38 ADA Box 34a - Diagnosis Codes
- 39 ADA Box 35 - Remarks
- 40 ADA Box 36 - Release of Information
- 41 ADA Box 37 - Signature on File
- 42 ADA Box 38 - Place of Treatment
- 43 ADA Box 39 - Enclosures
- 44 ADA Box 40 - Orthodontics
- 45 ADA Box 41 - Appliance Placement Date
- 46 ADA Box 42 - Treatment Remaining
- 47 ADA Box 43 - Prosthesis Replacement
- 48 ADA Box 44 - Prior Placement Date
- 49 ADA Box 45 - Treatment Resulting From
- 50 ADA Box 46 - Accident Date
- 51 ADA Box 47 - Accident State
- 52 ADA Box 48 - Office Name and Address
- 53 ADA Box 49 - Billing NPI
- 54 ADA Box 50 - Billing License Number
- 55 ADA Box 51 - SSN or TIN
- 56 ADA Box 52 - Office Phone Number
- 57 ADA Box 52a - Additional Provider ID
- 58 ADA Box 53 - Treating Dentist
- 59 ADA Box 54 - Treating Dentist NPI
- 60 ADA Box 55 - Treating Dentist License Number
- 61 ADA Box 56 - Treatment Location Address
- 62 ADA Box 56a - Treatment Provider Specialty Code
- 63 ADA Box 57 - Phone Number
- 64 ADA Box 58 - Additional Treatment Provider ID
ADA Box 1 - Type of Transaction
This box will default to put an X into Statement of Actual Services. MacPractice will put an X in the EPSDT box if the EPSDT checkbox is checked on the Insurance tab under the Patient screen.
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 Plan in the Ledger screen. Select the treatment charges and then from the Print pop-up menu select the Print Predetermination.
ADA Box 2 - Predetermination/Preauthorization
This box will be blank if there is no prior authorization and it will print None for a predetermination, as long as there is not a prior authorization number entered.
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 Auth tab of the Incident. There must be at least 1 remaining visit left for this to pull onto the claim.
The prior authorization number must also be selected in the insurance claim creation window from the Prior Auth pop-up menu.
ADA Box 3 - Company/Plan Name, Address, City, State, Zip Code
Information is populated with the name of the Insurance Carrier pop-up menu selection in the Claim Creation window, which pulls from the Primary or Secondary screen and the Plan pop-up menu selection.
If the plan is set to None, then the Street Address, State and Zip Code on the Company Info tab of the Insurance Company Reference will be printed.
If the plan is set to something other than None, then the Street Address, State and Zip Code on the Demographics tab of the Plan tab for the Insurance Company Reference of the guarantor's plan will be printed.
ADA Box 4 - Other Insurance Coverage
This box will default to No.
To have the box checked Yes go to the Insurance tab of the Patient screen and check the box to enable the second insurance.
You will also need to select the other insurance from the Other Insurance pop-up menu in the Claim Creation window.
ADA Box 5 - Other Coverage Subscribers Name
This box will be blank if there is no secondary insurance.
Information is populated by the Other Insurance pop-up menu selection in the Claim Creation window.
This information will pull the First, Middle and Last name fields for the insurance cardholder for the selected insurance.
ADA Box 6 - Other Coverage Subscriber's Date of Birth
This box will be blank if there is no secondary insurance. This information comes from the Birth Date field for the guarantor associated to the other insurance.
ADA Box 7 - Other Coverage Subscriber's Gender
This box will be blank if there is no Secondary Insurance.
This field pulls from the Gender pop-up menu for the guarantor associated to the other insurance.
ADA Box 8 - Other Coverage Subscriber's ID
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.
ADA Box 9 - Other Coverage Subscriber's Group Number
This box will be blank if there is no secondary insurance. This information comes from the Group Number field.
If an employer is selected in the pop-up menu, this is pulled from the Group Number field in the Employer table for the guarantor associated to the other insurance.
If the Primary Insurance is Medicare, Box 9 will print blank unless there is a MEDIGAP number entered in the Secondary Insurance Reference.
ADA Box 10 - Patient Relationship to Insured
This box will be blank if there is no secondary insurance.
Information is populated with the name of the other insurance selected in the Other insurance pop-up menu in the Claim Creation window.
This information will pull from the Relationship to Primary or Relationship to Secondary field in the Patient screen.
ADA Box 11 - Other Insurance Name and Address
This box will be blank if there is no secondary insurance.
Information is populated with the name of the other insurance selected in the Other insurance pop-up menu in the Claim Creation window.
This information will pull from the Primary or Secondary screen and the Plan pop-up menu selection.
If the plan is set to None, then the Street Address, State and Zip Code on the Company Info tab of the Insurance Company Reference will be printed.
If the plan is set to something other than None, then the Street Address, State and Zip Code on the Demographics tab of the Plan tab for the Insurance Company Reference of the guarantor's plan will be printed.
ADA Box 12 - Subscriber Information
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).
ADA Box 13 - Subscriber Birth Date
Information is populated from the Birth Date field for the guarantor associated to the primary insurance.
ADA Box 14 - Subscriber Gender
This information comes from the Sex pop-up menu for the guarantor associated to the primary insurance.
ADA Box 15 - Subscriber ID
Information is pulled from the Subscriber ID field for the associated insurance on the patient's Insurance tab in the Patient screen.
ADA Box 16 - Plan/Group Number
This information pulls from the guarantor's Group Number field. If an employer is selected in the pop-up menu, this is pulled from the Group Number field in the Employer table.
ADA Box 17 - Employer Name
Information is pulled from the Employer information selected in the Employer pop-up menu for the guarantor associated to the primary insurance.
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.
ADA Box 19 - Reserved For Future Use
This box is not populated through MacPractice at this time.
ADA Box 20 - Patient Name and Address
This field pulls the patient's name and address listed in the Patient's screen (Note: Name includes only First, Middle and Last name fields).
ADA Box 21 - Patient Birth Date
This box populates from the Birth Date field in the Patient's screen.
ADA Box 22 - Patient Gender
This box populates from the Birth Date field in the Patient's screenInformation is populated from the Sex pop-up menu in the Patient's screen.
Selecting Unknown in the Sex pop-up menu will leave this field unchecked.
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.
ADA Box 24 - Procedure Date
This information is pulled from the Procedure Date field in the charge window.
ADA Box 25 - Area of Oral Cavity
This box automatically fills in a two digit code, or a Left/Right indicator, designated by the “Area of Oral Cavity” pop up menu on the charge window.
This field can be overridden to print alpha characters (such as “LL” for lower left per insurance company) in the Insurance Company Reference > Claims tab using the “Print Quadrant” checkbox.
ADA Box 26 - Tooth System
MacPractice does not populate this information; it must be entered manually.
ADA Box 27 - Tooth Number/Letter
This box populates from the Tooth field in the charge window. If a range of teeth is being reported, use a hyphen to separate the first and last tooth in the range; otherwise commas are used to separate individual Tooth Number(s) or Letter(s).
ADA Box 28 - Tooth Surface
Information is populated from the Surface field in the charge window.
You can enter up to five of the surface codes without any spaces.
ADA Box 29 - Procedure Code
This box pulls from the Code field in the charge window.
ADA Box 29a - Diagnosis Pointer
The designator of A, B, C, or D are reflected in Box 34a from the ADA 2012 form.
ADA Box 29b - Quantity
This box pulls from the number of units designated in the new charge window.
ADA Box 30 - Procedure Description
Information in this box is pulled from the Procedure Description field in the charge window.
The procedure description is determined by the procedure code selected, which will pull from the Fee Schedule Reference.
ADA Box 31 - Fee Amount
Information is populated from the Total Fee field in the charge window, which is determined by the fixed fee amount or by the number of units multiplied by the unit fee in the charge window.
These fee amounts can be found in the Unit Fee field of the fee record in the Fee Schedule.
ADA Box 31a. - Other Fee(s)
MacPractice does not populate this information; it must be entered manually.
ADA Box 32 - Total Fee Amount
This field is populated by the Total Fee amount, which is calculated by adding up all the Box 31 fee amounts.
If the Other Fee amount needs to be included, you will need to manually enter the new Total Fee amount.
ADA Box 33 - Missing Teeth
MacPractice does not populate this information; it must be entered manually.
ADA Box 34 - Diagnosis Code List Qualifier
The Diagnosis Pointer is the line letter from Box 34a that relates to each diagnosis.
The Reference letter(s) should be A, B, C, D, or a combination of the four letters as applicable.
ADA Box 34a - Diagnosis Codes
This box pulls from the Diagnosis Codes from the new charge window.
The Diagnosis Codes will generate a letter corresponding to one of the four codes (A-D) that will appear in Box 29a.
ADA Box 35 - Remarks
This box populates from the Notes tab in the charge window.
The box for Print As Remarks on Claim (Box 35) must be checked for the information to be pulled onto the claim from the field below (this field is only available in MacPractice DDS).
ADA Box 36 - Release of Information
This field pulls from the guarantor's information on the Primary or Secondary screen by checking the Release of Information (box 36) box. The date for Box 36 is pulled from the date of the earliest charge of the created claim.
ADA Box 37 - Signature on File
This field pulls from the guarantor's information on the Primary or Secondary screen by checking the Signature on File (box 37) box.
It says:
"I hereby authorize and direct payment of the dental benefits otherwise payable to me directly to the below named dental entity."
ADA Box 38 - Place of Treatment
This information populates from the Place of Service pop-up menu selection in the charge window.
ADA Box 39 - Enclosures
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.
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.
ADA Box 40 - Orthodontics
This box will be checked No by default.
To have this box checked Yes, check the Orthodontics box under the Reason for Treatment tab inside of the Incident tab of the Incident.
ADA Box 41 - Appliance Placement Date
This field pulls from Box 41 Date Appliance Placed field under the ADA Claims tab of the Incident.
ADA Box 42 - Treatment Remaining
This box pulls from the Box 42 Months of Treatment Remaining under the ADA Claims tab in an Incident inside a patient's Ledger.
ADA Box 43 - Prosthesis Replacement
This box will be blank by default.
To have this box state Yes, select the Prosthesis box under the Reason for Treatment tab inside the Incident tab of the Incident.
It will state No if you select both the Initial Placement box and Prosthesis box under the Reason for Treatment tab inside the Incident tab of the Incident.
ADA Box 44 - Prior Placement Date
Information is populated from Box 44 Date Prior Placement field under the Claims tab of the Incident if you are running MacPractice DDS.
If you are NOT running MacPractice DDS, you can still access the ADA Claims tab by navigating to Preferences > Ledger > Incident > "Display both CMS and ADA Claim views".
ADA Box 45 - Treatment Resulting From
Information is populated in this box depending on the type of accident.
To have the Auto Accident box or the Other Accident box checked, select one of these from the Condition Related To pop-up menu under the Reason for Treatment tab inside the Incident tab of the Incident.
To have the Occupational Illness/Injury box checked, the Occupational Illness/Injury box under the Reason for Treatment tab inside the Incident tab of the Incident.
ADA Box 46 - Accident Date
This field pulls from the Accident Date field under the Incident tab of the Incident when the Condition Related To pop-up menu has Auto Accident or Other Accident selected.
ADA Box 47 - Accident State
Information is populated from the Accident State pop-up menu selection under the Reason For Treatment tab inside the Incident tab of the Incident when the Condition Related To pop-up menu has Auto Accident selected.
ADA Box 48 - Office Name and Address
Information is populated from the office name and address fields found in the Office Reference.
This information can only be changed or updated by MacPractice.
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.
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.
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.
ADA Box 50 - Billing License 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.
ADA Box 51 - SSN or TIN
This field pulls from the information entered in the Federal or SSN field found under the Provider Numbers tab of the User Reference.
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.
This box also populates from the Legacy Type Override pop-up menu under the Provider IDs tab of the Insurance Company Reference.
ADA Box 52 - Office Phone Number
Information is populated from the Phone field in the Office Reference.
ADA Box 52a - Additional Provider ID
Information is pulled from the Provider field under the Provider Numbers tab of the provider's User Reference.
ADA Box 53 - Treating 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.
ADA Box 54 - Treating Dentist 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.
ADA Box 55 - Treating Dentist License 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.
ADA Box 56 - Treatment Location 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.
If there is a facility in the charge window, the selected facility's address will be printed from the Facility Reference.
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.
ADA Box 56a - Treatment Provider Specialty 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.
ADA Box 57 - Phone Number
Information is populated from the Phone field under the User Information tab of the User Reference for the provider.
ADA Box 58 - Additional Treatment Provider ID
Information pulls into this box from the Paper ID field under the Provider IDs tab of the Insurance Company Reference.
