20:06:27:05Requirements for use of J512 Form.

The J512 Form shall be used as follows: (1) Dentists shall use the Dental Claim Form, J512, adopted by the American Dental Association as of 1994, according to instructions contained in the American Dental Association's Current Dental Terminology CDT-2, 1995-2000, for filing claims with issuers for professional dental services. When requested by the patient, dentists that bill patients directly shall provide the patient with a completed J512 Form in addition to any other form used to bill the patient; (2) Issuers may not require a dentist to use any code other than the CDT-2 codes for the initial filing of claims for dental care services, unless the use of supplemental codes is defined and permitted in a written contract between the issuer and dentist; (3) Dentists performing procedures within their scope of practice which do not have assigned CDT-2 codes may use the HCFA 1500 Form with the applicable CPT-4 codes. Issuers must accept the J512 Form or, as applicable, the HCFA 1500 Form.

Source: 22 SDR 97, effective December 18, 1995.