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Claim printing options can be set up for both the ADA 2006 form and the ADA 2012 form. The following tables describes the available print options for the ADA 2012 form.
| Option | Setting |
|---|---|
| [2] Preauthorization Number | Select one of the following:
|
| [8] Other Insurance Subscriber ID | Select one of the following:
|
| [15] Subscriber ID | Select one of the following:
|
| [20] Patient Name / Address | Select one of the following:
|
| [23] Patient ID / Account Nbr | Select one of the following:
|
| [25] Area of Oral Cavity | Select one of the following:
|
| [26] Tooth System | Check to print this box on claims. Uncheck to not print this box on claims. |
| [27] Tooth Numbers | Select one of the following:
|
| [28] Tooth Surface | Select one of the following:
|
| [29a] Diagnosis Pointer | Select one of the following:
|
| [29b] Quantity | Select one of the following:
|
| [31a &32] Other Fee(s) Line 1 & Total Fee - Total Location | Select one of the following:
|
| [34] Diagnosis Code List Qualifier | Select one of the following:
|
| [35] Remarks | Select one of the following:
|
| [43] Replacement for prosthesis | Select one of the following:
|
| [49] Provider ID/NPI | Select one of the following:
|
| [50] License Number | Select one of the following:
|
| [51] SSN or TIN | Select one of the following:
|
| [52a] Addl Provider ID | Select one of the following:
|
| [53] Certification | Select one of the following:
|
| [54] Provider ID/NPI | Select one of the following:
|
| [55] License Number | Select one of the following:
|
| [56] Address | Select one of the following:
|
| [56a] Prov Specialty Code | Select one of the following:
|
| [57] Phone Nbr | Select one of the following:
|
| [58] Addl Provider ID | Select one of the following:
|
| Option | Setting |
|---|---|
| [4] Other Dental or Medical Coverage | Select one of the following:
|
| [31a] Other Fee(s) - Line 1 - When zero dollar amount, display | Select one of the following:
|
| [31a] Other Fee(s) - Line 1 | Select one of the following:
|
| [32] Total Fee - When zero dollar amount, display | Select one of the following:
|
| [32] Total Fee | Select one of the following:
|