NextGen Knowledge Center

ADA (2019 and 2024) Form Options for All Payers

ADA OptionsDescription
[2] Preauthorization NumberOne of the following options display the pre-authorization or the predetermined number provided by the insurance company when you submit a claim for a pre-authorized procedure:
  • Authorization Number
  • Authorization Number – Upper Case
  • Blank
  • Referral Number
[8] Other Insurance Subscriber IDOne of the following options display the unique identifying number assigned by the insurance company to the patient's spouse, domestic partner, or a child:
  • Blank
  • Payer Policy Number
  • Subscriber SSN
[15] Subscriber IDOne of the following options display the unique identifying number assigned by the insurance company to the policy holder in box 12:
  • Blank
  • Payer Policy Number
  • Subscriber SSN
[20] Patient Name / AddressOne of the following options display the full name, address, and zip code of the patient:
  • Blank
  • None
  • Populate patient regardless of the subscriber
[23] Patient ID / Account NbrOne of the following options display the assigned number of dentist office to identify the patient:
  • Blank
  • Medical Record Number
  • Patient Control Number
  • Payer Policy Number
[25] Area of Oral CavityOne of the following options display the code that indicates the area of oral cavity:
  • Blank
  • Quadrant
By default, it displays the Quadrant value.
[26] Tooth SystemThis displays the code that identifies the system used. You can select the box to display JP or leave blank.
[27] Tooth NumbersOne of the following options display the tooth number or the range of teeth:
  • Blank
  • Tooth number
By default, it displays the Tooth number value.
[28] Tooth SurfaceOne of the following options display the code that identifies the surface:
  • Blank
  • Surface
By default, it displays the Surface value.
[29a] Diagnosis PointerOne of the following options display the letters from box 34 that identifies the diagnosis codes applicable to the dental procedure:
  • All Pointers
  • Blank
  • Primary Pointer
[29b] QuantityOne of the following options display the number of times (01-99) the procedure identified in box 29 is delivered to the patient on the date of service shown in box 24:
  • Always Quantity (Units)
  • Blank
  • Only when quantity is greater than 1 (one)
[31a & 32] Other Fee[s] Line 1 & Total Fee – Total LocationOne of the following options display the sum of all the other applicable charges to dental services provided:
  • Default to Total each page separately; no grand total
  • Grand Total on First Page Only; blank on other pages
  • Grand Total on Last Page Only; "Page X of Y" on other pages
  • Grand Total on Last Page Only; blank on other pages
  • Total each page separately; no grand total
[34] Diagnosis Code List QualifierOne of the following options display the code that identifies the diagnosis code source:
  • Under For ICD-9 print B in second space
    • If the diagnosis code is ICD-9, B is printed in block 2.
    • If the diagnosis code is ICD-10, AB is printed in both the blocks.
  • Under None
    • If the diagnosis code is ICD-9, B is printed in block 1.
    • If the diagnosis code is ICD-10, AB is printed in both the blocks.
[35] RemarksOne of the following options display the additional information the payer requires to process the claim:
  • Blank
  • Charge Narrative
  • Medical Record Nbr and charge narrative
  • Narrative w/o Charge Line Identifiers
  • Patient Control Number
  • Patient Control Number and Charge Narrative
[43] Replacement for prosthesisOne of the following options display based on whether the patient replaced his teeth by a crown or a fixed or replaceable prosthesis, like bridges and dentures:
  • Blank
  • No
  • Yes
[49] Provider ID/NPIOne of the following options display the NPI or Provider ID of the billing entity in box 48:
  • Blank
  • Phys Billing ID
  • Phys Billing NPI
[50] License NumberOne of the following options display the license number of the rendering dentist or the billing entity:
  • Blank
  • License number
[51] SSN or TINOne of the following options display the SSN or TIN of the entity in box 48:
  • Blank displays the SSN of an individual provider.
  • TIN displays the Tax ID number of the individual provider or group.
By default, it displays the TIN value.
[52a] Addl Provider IDOne of the following options display the provider ID of the billing dentist other than the SSN or the TIN:
  • Blank
  • Group ID Number
  • Group Taxonomy
  • Individual ID Number
  • Phys Billing ID
[53] CertificationOne of the following options display the signature of the rendering dentist and not the billing provider (unless the two are the same). The date is the server/system print date in MM/DD/CCYY format.
  • Blank
  • Rendering Name
  • Signature on File
  • UCASE[Signature on File]
By default, it displays the Signature on File value.
[54] Provider ID/NPIOne of the following options display the payer provider ID or NPI of the rendering dentist, not the billing entity NPI (unless the two are the same):
  • Blank
  • NPI number
  • Provider ID number
[55] License NumberOne of the following options display the license number or the payer provider ID of the rendering dentist:
  • Blank
  • License Number
  • Payer Provider ID
[56] AddressOne of the following options display the address, city, state, and zip code of the facility or location where the services are performed (not the provider’s address):
  • Addr City St Zip of billing dentist
  • Addr City St Zip of fac/loc where treatment performed if diff than of billing dentist; else Blank
  • Addr City St Zip of facility/location where treatment was performed
  • Blank
[56a] Prov Specialty CodeOne of the following options display the code that indicates the type of dental professional who delivered the treatment:
  • Blank
  • Taxonomy Code

    Displays the taxonomy code for the rendering provider or dentist.

[57] Phone NbrOne of the following options displays the phone number of the rendering dentist:
  • Blank
  • Phone number of billing dentist
  • Phone number of fac/loc where treatment performed if different than billing dentist, else blank
  • Phone number of facility/location where treatment was performed
[58] Addl Provider IDOne of the following options display the provider ID of the rendering dentists other than the SSN or TIN:
  • Blank
  • Opt Claim Value 1
  • Opt Claim Value 2
  • Payer Provider ID
ADA (2019 and 2024) Form Options for All Payers