For Dates of Service Before January 1, 2020

Other Insurance Indicators on American Dental Association Claim Forms

Providers should use the following information about insurance indicators when completing an ADA 2006 Claim Form or an ADA 2012 Claim Form.

When a member's enrollment is confirmed in Wisconsin's EVS, up to 26 other insurance indicators identifying the member's other insurance coverage may be indicated, if applicable. The following is a list of the indicators and descriptions most applicable to dental providers:

• 03 — DENT (Dental Major Medical Coverage)
• 13 — SDENT (Medicare Supplemental Dental Coverage)
• 23 — DENTO (Dental Only Coverage — Comprehensive Dental Coverage)

Insurance Indicator "23 — DENTO"

When the EVS indicates the code "23 — DENTO" for other coverage, submit claims for the following CDT procedure codes to the member's comprehensive commercial dental insurance prior to billing these procedures to ForwardHealth. The provider must be a member of the comprehensive commercial health insurance network of providers to receive reimbursement, if required by the commercial health insurance.

Insurance Indicator "03 — DENT"

When the EVS indicates the code "03 — DENT" for other coverage, submit claims for the following CDT procedure codes to the member's commercial health insurance prior to billing these procedures to ForwardHealth. The provider must be a member of the commercial health insurance network of providers to receive reimbursement, if required by the commercial health insurance.

Insurance Indicator "13 — SDENT"

When the EVS indicates the code "13 — SDENT" for other coverage, submit claims for the following CDT procedure codes to the member's commercial health insurance prior to billing these procedures to ForwardHealth.