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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 BlueCross BlueShield of Western 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. 

BlueCross BlueShield of Western 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.


  • Submitting Claims:


    All paper claims should be submitted to:
    BlueCross BlueShield of Western New York 
    P.O. Box 80
    Buffalo, New York 14240-0080

    Form Completion:


    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 BlueCross BlueShield of Western New York. 
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