MedicaidAdministrativeHigh impact
MAB2025051301
Pennsylvania Medicaid (DHS)·PA · Dentistry, Oral & Maxillofacial Surgery·Provider Bulletin
Effective date
May 1, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania's Medical Assistance program is transitioning from the 2019 ADA dental claim form to the 2024 version. Dental providers can use either form from May 1 through October 31, 2025, but must switch to the 2024 form by November 1, 2025.
Action Required
By November 1, 2025: Dental providers must transition to the 2024 ADA Claim Form for all Pennsylvania Medical Assistance claims. Order new forms from ADA at 1-800-947-4746 or ada.org. Update billing software to accommodate new fields (box 3a 'Payer ID', box 11a 'Other Payer ID', box 39a 'Date Last SRP', box 53a 'Locum Tenens Treating Dentist'). Claims submitted on 2019 forms after October 31, 2025 will be returned for resubmission.