Dental Claims
Provider Information
Dentist Name
Phone Number
Email Address
Treating Location
NPI (National Provider Identifier)
TIN (Tax Identification Number)
Next
Patient Information
*
indicates required fields
What type of dental transaction was this?
*
Statement of actual services
Predetermination / Preauthorization
Date of Service
*
Search Type
*
Individual
Family
Patient Information Member Search
*
Subscriber ID + DOB
First Name + Last Name + DOB
Subscriber ID
*
Date of Birth
*
Select a member below to continue
Member Details
Name Relationship Subscriber ID DOB Group Number
Previous
Next
Claim Information
To complete this section, you will need a copy of the patient’s bill or statement. You may need to enter procedure codes, locations, and fees for service, which can be found on the bill. View the list of possible information you may need to file this claim.
*
indicates required fields
Does the patient have additional insurance that applies to this claim? *
Yes
No
Does this claim include EPSDT / Title XIX? *
Yes
No
Please make a selection.
Who should be reimbursed for this claim? *
Provider
Member
Procedure

You entered high charge amount. Do you wish to continue?

Please enter at least one procedure.
Procedure Code
*
5-Character procedure code starting with ‘D’
Please enter a date of service.
Date of Service
*
Procedure Fee
*
Please enter a procedure fee.


Diagnosis Code(s)
Use ICD-10 formatting to fill in the diagnosis code (i.e. S32.101A). Codes that start with ‘D’ are considered procedure codes.
Units
1
Clear
Save Procedure
Additional Claim Information
Missing Teeth
Separate multiple tooth numbers with a comma (1, 7, 16)
Other Remarks
Content is limited to 250 characters
Please include any non-dental procedure diagnosis codes, electronic digital attachment ID's, office discounts applied, or other comments.
Does this claim include orthodontics?
*
Yes
No
Does this claim include prosthesis (crown, bridge, or denture)?
*
Yes
No
Does this claim relate to an accident/injury/illness?
*
Yes
No
Previous
Next
Upload Documents
To ensure timely processing of this claim, please upload documents associated with the patient’s procedure(s).
*
indicates required fields
Required Documents
Total Upload Space
0 MB
10 MB

Drag your .pdf, .png, .jpg, .jpeg, .txt, .tif, .tiff, .gif, or .bmp file here

or

Max. file size: 2MB each

Provider Narrative
Content is limited to 250 characters
Helpful Resources
Previous
Review and Sign