The J512 Form shall be used as follows:

1. (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. (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. (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.

   References: Form J512, adopted in 1994, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $25.20, plus $3.95 for shipping and handling.

   Current Dental Terminology CDT-2, Second Edition, 1995-2000, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $29.95.

   Physicians' Current Procedural Terminology CPT'95, Fourth Edition, 1994, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95, plus shipping and handling.

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

General Authority: SDCL 58-12-14.

Law Implemented: SDCL 58-12-12.