March 15, 2017

State of Alabama
Press Release: Medicaid

2012 ADA Dental Claim Form

PDF Version

TO:  Dental Providers

Effective June 1, 2017, Alabama Medicaid will only accept the 2012 ADA Dental Claim Form when a paper claim is required in order to process the claim.  Claims received after June 1, 2017 on any other claim form will be returned without being processed.

What is changing on the 2012 ADA Dental Claim Form?

The 2012 ADA Dental Claim Form allows providers to enter up to 4 diagnosis codes. However, diagnosis codes are NOT required to be present on the claim form.

A sample 2012 ADA Dental Claim Form and instructions for completing the form can be found in Chapter 5 of the provider billing manual (April 2017 edition).  Provider manuals are available for viewing online at the Medicaid website:

How do I obtain the 2012 ADA Dental Claim Form?

Providers may obtain the claim forms from a printer of their choice. HPE does not supply claim forms.

How should I prepare for this change?

Providers should notify their software vendor that Medicaid will require the 2012 ADA Dental Claim Form beginning on June 1, 2017. Some vendor changes may be required to ensure you can properly print the claim form.

As a reminder, all claims which do not require attachments or an Administrative Review override by Medicaid must be submitted electronically.

Questions should be directed to the Provider Assistance Center at 1-800-688-7989.

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2017 American Medical Association and © 2017 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.

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