OMB control number
ADA Dental Claim Form (CMS-10883)
OMB 0938-1471 · 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 can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
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Form and Instruction |
Form and Instruction |
Supporting Statement A |
Form CMS-10883 Paper Submission
CMS-10883.Supporting Statement Part A (3-28-24).docx
Paper Submission All Historical Document Collections
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Approved without change |
New collection (Request for a new OMB Control Number) | 2024-04-04 |
OMB Details
Electronic Submission
Federal Enterprise Architecture: Health - Health Care Services
| 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.