Dental Claim
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1 Provider information -
2 Patient and subscriber information -
3 Claim information -
4 Upload documents
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Claim information
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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.
Procedure(s)
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Amount you are requesting for this claim
$0.00
Discount applied to this claim
Upload documents
You have 0 fields that need to be corrected
To ensure timely processing of this claim, please upload documents associated with the patient's procedure(s). You may need the patient's:
- Periodontal chart(s) / X-rays
- Charting notes
- Billing statement
- Explanation of Benefits (EOB) from additional insurance, if applicable
Documents remaining 8
/of 8
Upload space remaining 20
/of 20MB
Accepted file formats: .pdf, .png, .jpg, .jpeg, .txt, .tif, .tiff, .gif, .bmp
If using a mobile device, please make sure it is capable of uploading documents.
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1 Provider information
Dentist first name
Dentist last name
Office address
Office address 2
City
State
Other location
5-digit ZIP Code
Phone number
Email address
NPI (National Provider Identifier)
TIN (Tax Identification Number)
2 Patient and subscriber information
Name | Member ID | Date of birth | Relationship |
---|---|---|---|
LYNN WYATT | 532861432 | 11/23/1969 | |
CHRISTOPHER D WYATT | 532861432 | 10/13/1999 | |
ANNA M WYATT | 532861432 | 11/18/2002 | |
ALYSSA WYATT | 532861432 | 05/29/1996 | |
DONALD R WYATT | 532861432 | 04/10/1965 |
You have field that need to be corrected
Patient first name CHRISTOPHER
Patient middle initial D
Patient last name WYATT
Patient date of birth 10/13/1999
Member ID 532861432
Group number 1070520
Address 1205 DONOVAN LN
Address 2
City EVERETT
State Washington
Other location
5-digit ZIP Code 98201
Phone number
If any additional/supplemental insurance was used to pay for any of this claim, add that information here.
Does the patient have additional insurance that applies to this claim? No
Add subscriber insurance details
3 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.
What type of dental transaction was this? Predetermination/Preauthorization
Preauthorization number
Who should be reimbursed for this?
Amount you are requesting for this claim
Missing teeth
Other remarks
Does this claim include orthodontics? No
When was the orthodontics appliance placed? Invalid date
Total number of months the patient received (or, is receiving) orthodontic care
Does this claim include prosthesis (crown, bridge, or denture)? No
Is this an initial placement of prosthesis (crown, bridge, or denture)?
Is this a replacement of prosthesis (crown, bridge, or denture)?
When was the prior placement? Invalid date
What was the reason for replacing the prosthesis?
Does this claim relate to an accident/injury/illness?
What type of accident/injury/illness?
When did the accident/injury occur? Invalid date
When did the accident/injury/illness occur? Invalid date
4 Upload documents
To ensure timely processing of this claim, please upload documents associated with the patient's procedure(s). You may need the patient's:
- Periodontal chart(s) / X-rays
- Charting notes
- Billing statement
- Explanation of Benefits (EOB) from additional insurance, if applicable
Uploaded documents
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.
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.
Dental Claim and Pre-treatment Estimate
Thank you
Your claim or predetermination has been submitted for processing.
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Confirmation details
Confirmation number | |
Submission date | |
Files attached | 1 |
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