ADA 2002 and 2000 claim forms now accepted by Wisconsin Medicaid

Effective immediately, Wisconsin Medicaid accepts the American Dental Association’s ADA 2002 and 2000 claim forms. Submit completed claims according to the instructions specific to the claim form. Refer to Attachments 1-4 of this Wisconsin Medicaid and BadgerCare Update for the ADA 2002 and 2000 claim form completion instructions and sample claims.

The ADA 2000 claim form instructions are included as a convenience for providers and do not replace the information in the July 2003 Update (2003-50), titled "Changes to local codes, paper claims, and prior authorization for dental services as a result of HIPAA." Providers should retain Update 2003-50 for their reference.

Wisconsin Medicaid’s claim instructions vary from the ADA instructions. The variations are necessary for Wisconsin Medicaid to process claims. Providers are required to complete the elements in the Wisconsin Medicaid instructions found in Attachments 1 and 3 as appropriate. No other claim form elements are required. In addition, providers are not required to include attachments to the claim form unless instructed to do so in the Dental Services Handbook.

Mail completed paper claims to:

Wisconsin Medicaid
Claims and Adjustments
6406 Bridge Rd
Madison WI 53784-0002

Note: As stated Update 2003-50, Wisconsin Medicaid does not accept the ADA 1994 claim form. Claims submitted on this claim form are denied.

Order ADA claim forms

Wisconsin Medicaid does not provide the ADA claim forms. To order the ADA 2002 or 2000 claim forms, do one of the following:

• Call the American Dental Association at (800) 947-4746.
• Order online at www.adacatalog.org/.

Information regarding Medicaid HMOs

This Update contains Medicaid fee-for-service information and applies to providers of services to recipients who have fee-for-service Medicaid or to recipients enrolled in Medicaid HMOs that do not provide dental coverage. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment 1: ADA 2002 claim form completion instructions for dental services
Attachment 2: Sample ADA 2002 claim form for dental services (PDF, 138 KB)
Attachment 3: ADA 2000 claim form completion instructions for dental services
Attachment 4: Sample ADA 2000 claim form for dental services (PDF, 101 KB)