Fillable DENTAL CLAIM FORM PLEASE TYPE OR PRINT Shaded

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DENTAL CLAIM FORM PLEASE TYPE OR PRINT Shaded

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City
Phone #
15. CROWNS, BRIDGES AND DENTURES:
Do services include the replacement of a prosthesis (crown, bridge, denture)?
If yes, what was the orginal prosthesis?
Indicate date of original placement or restoration and orignal teeth involved:
Reason for replacement: Original Damaged Lost or stolen Other:
See item 20 on the back of this form for x-ray requirements.
DENTAL CLAIM FORM
9. Is the patient covered under other dental insurance? No Yes
If yes, name of other insurance:
Name of Policy Holder
Other Policy ID Number
Identify Missing Teeth With “X”
To be completed by Dentist
(See instructions on reverse.)
1. Identification Number
4. Patient’s Date of Birth
2. Group Number or Enrollment Code 3. Patient’s Name
7. Subscriber’s Name
Subscriber’s Address
5. Patient’s Sex
Female Male
6. Patient’s Relationship to Subscriber: EE SP CH
8. Daytime Telephone Number
OFFICE USE ONLY
POI
SOPL
10.Was patient’s condition due to:
Work related accident?
An auto accident?
Other accidental injury?
No Yes
No Yes
No Yes
If yes, give the date of accident:
Please attach a statement with details indicating when, where and the manner in which the
injury occured.
Was another party at fault?
Mo. Day Year
12.ASSIGNMENT OF BENEFITS: (Please see the reverse side of this form for further information.)
If "yes" block above is marked, I authorize the Blue Cross and Blue Shield Plan to pay
benefits directly to the provider of the services listed below.
The Plan may, at its discretion, accept or deny an assignment of benefits.
13.MISSING TEETH:
Identify missing teeth on chart with X. Indicate by tooth number,
the date each tooth was lost or extracted, if known:
TOOTH DATE TOOTH DATE
14. ORTHODONTIA:
Is orthodontic treatment included in the services listed
below?
If yes, is this initial treatment?
Date appliance was placed:
Expected completion date
of orthodontic treatment:
Total charge for active treatment
RPL
SPI
Mo. Day Year
Mo. Day Year
Tooth Number(s)
16. Do charges include a consultation? No Yes If yes, name of referring provider
A report from the consulting specialist is required. See item 16 on the back of this form for additional information required for a consultation.
19. TOTAL CHARGE
OFFICE USE ONLY
17. Description of Services (See instructions on reverse.)
Date of Service
M D Y
A.D.A.
Procedure
Code
Detailed Description of Services
Tooth No.
or
Letter
Surfaces
No. of
Times
Perf.
Place
Charge
Other
Ins. Cons.
Other
Ins. Paid
A
D
I
Remarks, Notes
P = RC =
20. Are x-rays enclosed?
(See item 20 on the back of this form.)
21.
Reviewed By:
PAY
18. Please check the appropriate box.
ESTIMATE OF ELIGIBLE BENEFITS
The treatment listed is necessary in my professional judgement and I
request . Note: Dentist’s Tax ID Number or
Social Security Number is required.
WORK COMPLETED - PAYMENT REQUESTED
I certify that the services have been performed by me or under my
personal supervision and are necessary in my professional judgement.
Charges shown are my usual charges.
O
F
F
I
N
O
P
11.THIS CLAIM FORM MUST BE SIGNED. IF NOT, IT WILL BE RETURNED. I certify that the above
information is correct and apply for benefits under my dental coverage. I authorize any dentist
or physician in possession of information concerning the patient to furnish such information
upon request.
PLEASE TYPE OR PRINT
Shaded Area is for Plan Use Only
YesNo
Tax ID No. or SSN
YesNo
YesNo
YesNo
YesNo
YesNo
(explain)
(First, Middle Initial, Last)
(
Include Area Code
)
Self
Spouse
Child
Zip Code
State
City
CHECK IF NEW ADDRESS
Other
Explain:
(Street and Apt. or Box Number)
(First, Middle Initial, Last)
Dentist’s Signature
State
Zip Code
Dentist’s Name
Address
Date
Signature of Subscriber or Spouse
Signature of Subscriber or Spouse
Date
CUT0131-1S
Email Address
12/13
Estimate of Eligible Benefits
CUT0131-1S Rev. 2/09
DENTAL CLAIM FORM
CUT0131-1S 12/13
Use this claim form to submit a claim for services which are covered under your dental program. To avoid delay in having your claim processed, please
by the subscriber or spouse, and items 13 through 21 are to be completed by the dentist.
When the claim form has been completed and signed, please mail it to your local Blue Cross and Blue Shield Plan.
INSTRUCTIONS FOR COMPLETING PATIENT AND SUBSCRIBER INFORMATION
Items 1-11: Complete all items as indicated on the front of the form.
Item 9: Please check yes or no in item 9. If yes, please provide information requested regarding your other dental insurance coverage. If payment has
been received from another insurance company, please attach a copy of their Explanation of Benefits.
Item 12: ASSIGNMENT OF BENEFITS - Benefits for services provided by participating dentists are made payable directly to the dentist, whether or not
benefits are assigned. Benefits for services provided by non-participating dentists located within our service area are made payable directly to
the subscriber, regardless of any assignment of benefits. However, if the non-participating dentist is located outside our service area and you
would like benefits due you for this claim sent directly to the dentist, complete item 12 on the reverse side of this form. Also, be sure the
dentist’s Tax ID Number or Social Security Number is included in item 21 with the dentist’s name and address.
INSTRUCTIONS FOR COMPLETING DENTIST INFORMATION
Item 13: MISSING TEETH - Each claim for services involving missing or extracted teeth must include the information requested in item 13. To assist
us in updating our records, with the submission of an initial oral exam, please include a complete charting of the patient’s dentition.
Item 14: ORTHODONTIA - Claims for orthodontic services must include the information requested in item 14. It is not necessary for the orthodontic
treatment to be completed before submitting the claim.
Item 15: CROWNS, BRIDGES AND DENTURES - Please complete this information on any claim for a crown, bridge or denture. See item 20 below for
x-ray requirements.
Item 16: CONSULTATIONS - Claims for consultations must include a report from the consulting specialist indicating the name of the referring dentist or
physician, the reason for the consultation, the treatment being considered and a description of the patient’s oral condition.
Item 17: ADA PROCEDURE CODES - American Dental Association codes
TOOTH NO. OR LETTER - Refer to tooth chart on front of this claim form.
SURFACES - Use the following codes to identify tooth surfaces:
B = Buccal or facial D = Distal O = Occlusal
M = Mesial I = Incisal L = Lingual
PLACE - Please check the appropriate column on the claim form to indicate the place of service:
Off = Office IN = Inpatient Hospital OP = Outpatient Hospital
CHARGE - Indicate the individual charge for each service listed.
Item 18: DENTIST’S CERTIFICATION AREA - Please check the appropriate box to indicate whether the services listed have been completed. The
dentist’s signature and telephone number must also be completed in item 18.
ESTIMATE OF ELIGIBLE BENEFITS - If no dates of service are indicated on the claim, we will provide an estimate of the benefits available
for the services listed. The estimates are based on the information we have at the time the claim is reviewed. Estimates will be subject to
eligibility, deductibles, and Plan maximums. Therefore, they may be affected by other payments made between the time the estimate is given
and the time that the services are rendered. Actual payments will be made in the order that the claims are received.
If you are requesting a Estimate of Eligible Benefits, mark the Estimate of Eligible Benefits box in item 18. In addition, the dentist’s name, address,
and Tax ID Number or Social Security Number must be clearly written in item 21 of this claim form.
Item 20: X-RAYS - Post-operative x-rays are required for the review of claims for root canals. These x-rays are also needed to review claims for posts
and cores following the root canals. Pre-operative x-rays are required for review of claims for crowns, crown build-ups, bridges, partial
dentures and apicoectomies. For periodontal procedures, we need the most recent pre-operative x-rays and complete periodontal charting of
the teeth involved in the treatment. We may also occasionally request x-rays for certain other procedures. All x-rays will be returned to the dentist
after the claim has been reviewed. To expedite the processing of your claim and to assist us in the return of the x-rays, please include the
patient’s name and identification number as well as the dentist’s name and address on the x-ray envelope.
Item 21: Each claim must include the dentist’s name, address and Tax ID Number or Social Security Number. Please also check the appropriate box in
item 21 to indicate the type of identification number used.
complete a separate claim form for each patient, and be sure that all information is complete and correct. Items 1 through 12 of this form must be completed
GENERAL INFORMATION
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Completed 26 February 2021

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