Completing the American Dental Association Dental Claim Form
This guide is designed to highlight the fields of the ADA Dental Claim Form that are required when submitting to BlueShield of Northeastern New York. All required fields of the claim form must be completed, or the claim may be returned for additional information.
Please reference to section 6 of the dental manual for more information.
BlueShield of Northeastern New York prefers that providers submit their claims electronically. Contact your EHR vendor or visit our provider portal, ASK-EDI section, for more information on how to submit claims electronically.
All paper claims should be submitted to:
BlueShield of Northeastern New York
P.O. Box 80
Buffalo, New York 14240-0080
The following pages detail how to complete the ADA Dental Claim form. If you have any questions, please contact your Network Representative.
Dental Claim Form Instruction Guide
Key and field descriptions
Important Information Regarding Blue Card Members:
- Claims for services provided to members of other BlueCross and/or BlueShield plans should always be submitted directly to the home plan, not to BlueShield of Northeastern New York.