Header and plan information (items 1 to 3a)
The type of transaction, the predetermination/preauthorization number, the company or plan name and address, and the payer ID.
CMS-10883
ADA Dental Claim Form
- Agency
- CMS
- Revision
- 2024-08-01
- Fillable fields
- 220
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10883: American Dental Association (ADA) Dental Claim Form
Form CMS-10883 is the American Dental Association (ADA) Dental Claim Form. The CMS forms page lists it as the ADA Dental Claim Form with OMB No. 0938-1471, a revision date of 2024-08-01 and an OMB expiration date of 2027-05-31. The form itself carries a 2024 American Dental Association copyright and the code J43024.
The form is a claim sent to a third-party payer, which its instructions describe as an insurance company or dental benefit plan. Item 1 offers three transaction types: Statement of Actual Services, Request for Predetermination/Preauthorization, and EPSDT / Title XIX. The rest of page 1 covers the dental benefit plan, other coverage, the policyholder or subscriber, the patient, a record of up to 10 services with diagnosis codes, authorizations, ancillary claim and treatment information, the billing dentist or dental entity, and the treating dentist.
Page 2 highlights certain completion instructions and says the comprehensive instructions are posted on the ADA's website. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10883
Other coverage (items 4 to 11a)
Whether there is other dental or medical coverage, with the other policyholder's name, date of birth, gender, ID, plan/group number, the patient's relationship to them, and the other plan's name, address and payer ID. The form says to leave these blank if there is none.
Subscriber and patient (items 12 to 23)
The policyholder or subscriber's name, address, date of birth, gender, ID, plan/group number and employer, then the patient's relationship to them, name, address, date of birth, gender and patient ID/account number assigned by the dentist.
Record of services (items 24 to 35)
Ten lines for procedure date, area of oral cavity, tooth system, tooth numbers or letters, surface, procedure code, diagnosis pointer, quantity, description and fee, plus other fees, total fee, a missing teeth chart, diagnosis codes and remarks.
Authorizations and ancillary information (items 36 to 47)
Patient or guardian and subscriber signatures, place of treatment, enclosures, date of last SRP, orthodontic treatment details, replacement of a prosthesis, and whether treatment resulted from an occupational illness or injury, auto accident or other accident.
Billing and treating dentist (items 48 to 58)
Name, address, NPI, license number, SSN or TIN, phone and additional provider ID for the billing dentist or dental entity, and the treating dentist's signature, locum tenens box, NPI, license number, address, specialty code and phone.
The form has 58 numbered items on page 1 and highlighted instructions on page 2.
How to fill out Form CMS-10883
- 1
Mark the type of transaction
Mark all applicable boxes in item 1 and add a predetermination/preauthorization number in item 2 if there is one.
- 2
Enter plan, subscriber and patient details
The instructions say all dates include the four-digit year (MM/DD/CCYY) and give the gender codes as M for male, F for female and U for unknown. Full names and addresses with ZIP codes go in each name and address field.
- 3
List each procedure
Fill one line per procedure in the Record of Services Provided. If there are more procedures than lines, the instructions say to list the rest on a separate, fully completed claim form.
- 4
Add diagnosis codes
Item 34 takes the qualifier AB for ICD-10-CM and item 34a takes up to four diagnosis codes, with the primary next to the letter A. Item 29a points each procedure to codes A to D.
- 5
Complete place of treatment and specialty
Enter the 2-digit Place of Service Code in item 38, for example 11 for office or 22 for outpatient hospital, and the provider specialty code in item 56a. The instructions say the general Dentist code 122300000X may be used instead of the other codes.
- 6
Sign and send to the payer
Collect the signatures in items 36, 37 and 53 that apply, then send the claim to the payer named in item 3. The form is laid out so that address shows in a standard #9 window envelope.
Why fill Form CMS-10883 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, codes and help
Where to send it
To the third-party payer named in item 3, which the instructions describe as the insurance company or dental benefit plan. The instructions say to fold the form using the tick marks in the margin so the address fits a standard #9 window envelope.
Secondary payer claims
The instructions say to complete the entire form and attach the primary payer's Explanation of Benefits. The amount the primary carrier paid may also be noted in Remarks, item 35.
Full instructions
Page 2 says the comprehensive ADA Dental Claim Form completion instructions are posted on the ADA's website at ADA.org/en/publications/cdt/ada-dental-claim-form.
Code lists
Page 2 lists common Place of Service Codes: 11 Office, 12 Home, 21 Inpatient Hospital, 22 Outpatient Hospital, 31 Skilled Nursing Facility and 32 Nursing Facility. It points to cms.gov for the full list and to nucc.org for the full provider taxonomy code set.
OMB number
The form shows Approved OMB No. 0938-1471. The CMS page lists an OMB expiration date of 2027-05-31.
The copy on the CMS page
The PDF on the CMS page carries a large SAMPLE watermark across page 1. The form prints ADA reorder details: 800.947.4746 or ADAstore.org.
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Who uses Form CMS-10883?
The form has separate parts for the patient, the subscriber, the billing dentist or dental entity and the treating dentist.
Official sources and the blank
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Questions about Form CMS-10883
What is Form CMS-10883?
It is the American Dental Association (ADA) Dental Claim Form, listed on the CMS forms page under OMB No. 0938-1471. It is a claim sent to an insurance company or dental benefit plan.
Can Form CMS-10883 be used for a predetermination?
Item 1 offers Request for Predetermination/Preauthorization as one type of transaction, next to Statement of Actual Services and EPSDT / Title XIX.
What if there are more than 10 procedures?
The instructions say to list the remaining procedures on a separate, fully completed claim form.
How many diagnosis codes can be reported?
The instructions say the form supports up to four diagnosis codes per dental procedure. They go in item 34a with the primary next to A, item 34 takes the qualifier AB for ICD-10-CM, and item 29a links each procedure to them.
When is the billing dentist section left blank?
The form says to leave items 48 to 52a blank if the dentist or dental entity is not submitting the claim on behalf of the patient or insured/subscriber.
What goes in Place of Treatment?
The instructions say to enter the 2-digit Place of Service Code for Professional Claims, for example 11 for office, 12 for home or 22 for outpatient hospital.
Where are the full instructions for Form CMS-10883?
Page 2 says the comprehensive completion instructions are posted on the ADA's website at ADA.org/en/publications/cdt/ada-dental-claim-form.