Dental Claim Form

Patient Information

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What type of dental transaction was this?

Statement of actual services

Predetermination / Preauthorization

If member is part of a DHMO, DCDC, or ENDP plan, you are not able to request a PTE.

Date of Service

Search Type

Individual

Family

Patient Information Member Search

Subscriber ID + DOB

First Name + Last Name + DOB

Subscriber ID

Date of Birth

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Member Details

Name	Relationship	Subscriber ID	DOB	Group Number

Upload Documents

To ensure timely processing of this claim, please upload documents associated with the patient’s procedure(s).

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Required Documents

Total Upload Space

0 MB

10 MB

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

Max. file size: 2MB each

Provider Narrative

Content is limited to 250 characters

Provider Narrative is included in an attachment

Helpful Resources

Clinical guidelines (Commercial Only)

Clinical guidelines (Medicare Only)

Review and Sign

Provider Information

Dentist Name

Phone Number

Email Address

Treating Location

NPI (National Provider Identifier)

TIN (Tax Identification Number)

Patient Information

What type of dental transaction was this?

Claim Information

Does the patient have additional insurance that applies to this claim?

Does this claim include EPSDT / Title XIX?

Who should be reimbursed for this claim?

D2542 - Procedure Description

10/01/2019 • $1,000.00

Tooth Number: 1-10
Tooth Surface: A
Diagnosis codes(s):
Units: 1
Documentation Required:

Missing Teeth:

Other Remarks:

Does this claim include orthodontics?

Date Orthodontics Appliance was Placed:

Number of Months Patient Received/is Receiving Orthodontic Care:

Does this claim include prosthesis (crown, bridge, or denture)?

Date of Prior Placement:

Reason for Replacement:

Does this claim relate to an accident/injury/illness?

Type of Accident/Injury/Illness

Date of Accident/Injury/Illness

Uploaded Documents

Provider Narrative:

Fraud Notice

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Acknowledgment and Signature

I certify that the procedures indicated on this form are either in progress or have been completed. I understand that by putting my name in the field below, I am signing this form electronically.

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Provider Acknowledgment

The dentist or dental office has explained the dental treatment plan and costs to the patient or authorized representative. The office has a patient or authorized representative signature stating that the patient or authorized representative will be responsible for all charges for dental services and materials not paid by the patient’s dental benefit plan, unless the charges are not allowed by law. The patient or authorized representative has also agreed in writing that the dentist or dental office can use and disclose the patient’s protected heath information in order to process this claim.

Payment Acknowledgment

The dentist or dental office has a signature on file of the patient or authorized representative allowing direct payment to the dentist or dental office.

Provider’s Signature

Today’s Date

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