CDA (Canadian Dental Association) Form at a Glance

Owned by Dylan Nigh
Last updated: Oct 05, 2023
8 min read

CDA Part 1 - Unique No

This is the Patient ID that is automatically assigned to each patient in MacPractice.

CDA Part 1 - Patient's Office Account No

This is the Patient ID that is automatically assigned to each patient in MacPractice.

CDA Part 1 - Patient

The Patient field pulls from the Patient tab in the Patients ability and includes the following information:

  • Patient First Name, Patient Last Name

  • Patient Street Address

  • Patient Suite/Apt #

  • Patient City, State, Zip Code

CDA Part 1 - Dentist

The Dentist box pulls from the claim provider whose User Reference has "Is Provider" checked and the Office Reference as set under the User Reference of the provider. This field includes the following information:

  • Claim Provider Title, First Name, Last Name and Suffix

  • Office Street Address, Suite

  • Office City, State, Zip Code

  • Phone No.: Office Phone Number

CDA Part 1 - Signature of Subscriber

This information pulls from the guarantor's information in the Primary or Secondary tabs. The Accepts Assignment checkbox in the Insurance Company box > Provider IDs tab must be checked for the signature to pull properly.

You'll need to scroll to the right to see the "Provider Accepts Assignment" checkbox for each Provider. You can also edit this information via References > Insurance Companies.

CDA Part 1 - For Dentist Use Only

This field can be used to add additional information, diagnoses, procedures or special considerations.

When "Accepts Assignment" is checked, "Please Pay Provider" will be printed in this field. When unchecked, "Please Pay Patient" will be printed.

If printing a predetermination for a treatment plan, this box will display "Predetermination Only."

You may also choose to enter additional notes; these populate from the Notes tab within the Charge window. You must check "When checked, notes will be filled in Box 35 in Insurance form" box in order for these notes to pull onto your claim.

CDA Part 1 - Date of Service

The Date of Service field pulls from the Procedure Date in the charge window.

CDA Part 1 - Procedure Code

This box pulls from the Code field in the charge window.

CDA Part 1 - Int'l Tooth Code

This information pulls 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 numbers.

CDA Part 1 - Tooth Surfaces

Information is populated from the Surface field in the charge window. You can enter up to five of the surface codes without any spaces.

CDA Part 1 - Dentist's Fee

The information for this box pulls differently based on whether or not the Add Lab Fees to Patient Portion checkbox is selected.

Checked

When checked, this box allows the addition of the Lab Fee portion to your Unit Fee for billing the patient.

When Insurance Estimating is on, this will also put the Lab amount in the Patient Portion and will not be reflected in the Estimate.

If Insurance Estimating is not used, the entire charge amount will be in the Insurance Portion while the claim is open.

Unchecked
When unchecked, the unit Fee is the Total Fee billed on the claim. The Lab Fee is the Lab Charge amount. The Lab Fee gets added to the Unit Fee to calculate the Dentist's Fee.

Unit Fee + Lab Fee = Debit/Total Fee

When Insurance Estimating is on, since the Unit Fee is the entire amount for both Procedure and Lab, the Lab is Included in the Estimate.

If Insurance Estimating is not used, the entire charge amount will be in the Insurance Portion while the claim is open.

CDA Part 1 - Laboratory Charge

There are two ways the Laboratory Charge can pull information. It can pull so that a single line displays the fee and the charge on one line. It can also pull so that the Laboratory Charge is billed on a separate line.

Single Line
For some procedures the procedure with its associated Dentist Fee and Laboratory Charge should be printed on one line.



The Laboratory Charge should be entered in the Lab Code Box in the New Charge Window. Enter the Charge in the Fee field.

Note: It is possible to permanently attach a Lab Code to a Procedure. References > Fee Schedules > Select the Code > Specialty Tab > CDA Lab Code, click the green plus and add your Lab Code here.

Multiple Lines

Some procedures may require that a Laboratory Charge is billed on a separate line.

Enter the office code first in the charge window. If additional lab materials are used for the office procedure enter this in the lab fee box in the bottom right hand corner and it will print on the same line as the procedure. Then click the plus button at the bottom of the charge window to enter another procedure line item. Enter the lab code in the procedure box. The procedure code and lab code now print on two lines on the claim.

CDA Part 1 - Total Charges

This field totals the amounts in the Dentist's Fee and Laboratory Charge fields.

CDA Part 1 - Total Fee Submitted

This field sums Dentist's Fees and Laboratory Charges for all Procedure Codes included on the claim.

CDA Part 2 - Group Policy/Plan No.

This field pulls from the Policy # field in the Insurance section of the Primary or Secondary tab.

CDA Part 2 - Division/Section No

This information will pull from the Division/Section field in the Insurance Section of the Primary or Secondary tabs.

CDA Part 2 - Employer

The Employer field will pull from the Employer information selected in the Employer pop-up menu for the guarantor associated to the Insurance carrier selected in the Claim creation window.

CDA Part 2 - Name of Insurance Agency or Plan

This field pulls the Insurance Carrier to whom the claim is being submitted, per the Claim creation window.

CDA Part 2 - Your Name

This field displays the guarantor's First, Middle and Last Name.

CDA Part 2 - Your Cert. No or S.I.M. or I.D. No

This information pulls from the Subscriber # field in the Insurance Section of the Primary or Secondary tabs.

CDA Part 2 - Your Date of Birth

This box is pulled from the guarantor's Birth Date as displayed in the Primary or Secondary tabs.

CDA Part 3 - Patient: Relationship to Employee/Plan Member/Subscriber

This field pulls from the Relationship to Primary or Secondary pop-up menu in the Patient tab.

CDA Part 3 - Date of Birth

This information pulls from the Birth Date field in the Patient tab.

CDA Part 3 - If Student, Indicate School

This information will pull from the School Name field located in the CDA tab within the Patient tab.

CDA Part 3 - Patient I.D. No

The Patient I.D. Number is pulled from the Subscriber field, located in the Insurance tab within the Patient tab.

CDA Part 3 - Other Group Insurance or Dental Plan

This box will be checked if the patient has secondary Insurance. This information will pull from the Other Insurance pop-up menu on a Claim creation window. If set to None, the No box will be checked.

CDA Part 3 - Policy No

The Policy Number will pull from the Policy # field in the Insurance tab, as determined by the secondary guarantor's Insurance Policy Number.

CDA Part 3 - Spouse Date of Birth

This field will pull information from the Date of Birth field of the secondary guarantor.

CDA Part 3 - Name of Other Insuring Agency or Plan

This field pulls the name of the secondary Insurance, as selected in the Claim creation window.

CDA Part 3 - Treatment Required as the Result of an Accident

This box will be checked Yes, if the "Condition Related To" drop down menu option is set to Auto Accident or Other Accident. You can find this by selecting an Incident in the sidebar, and then navigating to the "Reason For Treatment" sub-tab.

CDA Part 3 - Denture, Crown or Bridge Initial Placement

This information will pull from the Initial Placement checkbox. This checkbox is located in the Ledger. Select an Incident, and then click the "Reason for Treatment" sub-tab. 
When the Initial Placement box is checked, the claim will consequently have the "Yes" box checked.

CDA Part 3 - Treatment Required For Orthodontic Purposes

This information will pull from the Orthodontics checkbox. This checkbox is located in the Ledger. Select an Incident, and then click the "Reason for Treatment" sub-tab. 
When checked, the Yes box will be checked on the claim.

CDA Part 3 - Signature of Employee/Plan Member/Subscriber

The Signature of Employee/Plan Member/Subscriber will pull from the Accepts Assignment drop down in the Insurance box. The Date will pull from the Procedure Date, as entered in the charge window.

CDA Part 4 - Policy Holder/Employer

If a patient's insurance plan requires submission to their employer, you must direct the claim form to the patient's personnel office/plan administrator who will complete part 4 and forward the form to the insurance carrier.