The J404 2006 ADA claim form has been discontinued and is formatted slightly different from the newer J434 claim form. The J434 ADA claim form contains new fields which will allow dental providers to place the International Classification of Diseases (ICD-9) codes that are used to report diagnoses associated with inpatient, outpatient, physician and dental office
services.

 ADA 2012 Dental Claim Form Changes

• Field 4  Changed options to "Dental" or "Medical" This field is not required.
  
• Field 29a Diag. Pointer  If you enter a diagnosis in field 34a, you will need to enter the corresponding letter in field 29a.
  
• Field 29b Qty.  Enter the correct quantity of the service(s) provided.
• Field 31a Other Fee(s)  Previously field 32, this field is not required.
• Field 32 Total Fee  Previously field 33  Enter the total of all fees.
• Field 33 Missing Teeth Information  Removed primary teeth designation.
• Field 34 Diagnosis Code List Qualifier  If you enter a diagnosis code on your claims, you will need to enter "B" for an ICD-9 diagnosis code or "AB" for ICD-10 diagnosis code.  At this time you will always enter "B"
• Field 34a Diagnosis Code (s)  Enter the primary diagnosis in field "A". Any additional diagnosis codes are to be entered in fields B-D.
• Field 38 Place of Treatment  Enter place of service code, e.g. 11- office or 22-O/P hospital.
• Field 39 Enclosures  (Y or N) this field is not required.

For providers who utilize practice management software to submit claims,
please check with your software vendor to ensure the vendor is able to print the J434 ADA claim forms. Otherwise, the claims will be returned beginning on May 1, 2013.

Please refer to provider manual Chapter 8 "Provider Specific Claims Submission Instructions" for complete claims submission instructions. The provider manuals can be accessed and downloaded by going to the Connecticut Medical Assistance Program Web site: www.ctdssmap.com. From this Web page, go to "Information", then to "Publications" scroll down to Provider Manuals, Chapter 8 and select "Dental" in the drop down box.

There are no changes in how claims are submitted electronically or through the provider secure Web site: www.ctdssmap.com.

Dental claims can be submitted through the Web by signing into the provider secure Web site, go to "Claims" and click on "Dental". Please refer to the quick links "Instructions for submitting Dental Claims" for claim submission assistance on the dental claim page.

If you have any questions regarding this bulletin, please contact the HP Provider Assistance Center at 1-800-842-8440.