OMB control number
ADA Dental Claim Form (CMS-10883)
OMB 0938-1471 ยท HHS/CMS.
OMB 0938-1471
Medicare Administrative Contractors (MACs) will use the data collected on the ADA Dental Claim Form to determine the proper amount of reimbursement for Part B dental services (as listed in section 1861(s) of the Social Security Act) provided by dental providers to beneficiaries. The ADA Dental Claim Form is submitted by dental providers for Part B Medicare.
The latest form for ADA Dental Claim Form (CMS-10883) expires 2027-05-31 and is listed under ICR 202403-0938-016.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10883 Paper Submission | Form and Instruction |
 Form CMS-10883 Electronic Submission | Form and Instruction |
| CMS-10883.Supporting Statement Part A (3-28-24).docx | Supporting Statement A |
 Paper Submission |
Form and Instruction |
| Electronic Submission |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202403-0938-016 | New collection (Request for a new OMB Control Number) | 2024-04-04 | Approved without change |
OMB Details
Electronic Submission
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10883 | ADA Dental Claim Form | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.