Fillable Dental Claim Form (Orange County Community College)

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Dental Claim Form (Orange County Community College)

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U.S.A. forms for Orange County Community College

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Part 1: To be completed by Employee
For faster payment, submit electronically
1. Patient’s full name (first, middle initial, last) 2. Patient birthdate (MM/DD/YY)
3. Relationship to employee
Self Spouse Child Other
4. Sex
M F
5. Employee’s full name (first, middle initial, last) 6. Employee’s identification number Employee’s birthdate (MM/DD/YY)
7. Employee’s mailing address (street address or P.O. Box, City, State, ZIP)
Email address:
8. THIS SECTION MUST BE COMPLETED WITH EACH CLAIM SUBMISSION ONLY
IF THE CLAIM IS FOR A DEPENDENT CHILD AGE 19 OR OVER
Is patient a full-time student?
Yes No
If Yes, name
and address
of school:
9. Employer (company)
name and address
10. Group number Division number Certificate number
Questions 11 and 12 must be completed with each claim submission.
11. Is patient covered by
another dental plan?
Yes No
Name and address of other carrier Policy number Name and address of other employer
12. Other employee/subscriber name
Employee/subscriber identification number
Date of birth (MM/DD/YY)
Relationship to patient
13.
I have reviewed the following treatment plan, and I authorize release of
any information relating to this claim. I understand that I am responsible
for all cost of dental treatment. I certify these statements to be true and
complete to the best of my knowledge.
X
Signature (patient, or parent if minor)
Date
14. I hereby authorize payment directly to the below named dentist of
group insurance benefits otherwise payable to me.
X
Signature (patient, or parent if minor)
Date
Part 2: To be completed by Attending Dentist. Please provide Current Dental Terminology © American Dental Association procedure codes.
15. Dentist name and mailing address For Yes answers to questions 18-20, enter a brief description and dates.
18. Is treatment result of occupational illness or injury?
Yes No
19. Is treatment result of auto accident?
Yes No
Specialist designation
General anesthesia permit #
20. Other accident ? Yes No
Phone number Fax number
21. If Prosthesis, is this initial placement?
Yes No
If no, reason for replacement and date of prior replacement:
Email
22. Is treatment for orthodontics?
Yes No
If services have begun, enter date appliances placed and months remaining:
16. Dentist
SSN TIN
NPI (Nat. Provider Identifier)
License #
17. Radiographs or models enclosed?
Yes No
How
many?
23. This is a (please check one):
Statement of actual services
Pretreatment estimate
24. Examination and Treatment Record
Tooth number, letter,
quadrant or arch Surfaces
DESCRIPTION OF SERVICES
(including x-rays, prophylaxis, materials used, etc)
CDT © ADA
Procedure Code
Date Service Performed
Fee
Month
Day Year
25. Remark s for
unusual services
26. Total fee charged
27.
Certification: I hereby certify that the services listed above have been performed on the
dates indicated and that the fees subm itted are the fees I have charged and intend to
collect for those purposes.
X
Signature (Dentist)
Date
28. Address where treatment was performed
FA 32 Rev. 2-15 02-26-15
dental Group Claim Form
Ameritas Life Insurance Corp. of New York
Group Claim Office / P.O. Box 82595 / Lincoln, NE 68501-2595 / Toll Free 800-659-5556 / Fax 402-467-7336 / Web ameritas.com
Ameritas’ payer ID for electronic claims is 72630.
RESET FORM
FA 32 Rev. 2-15 02-26-15
tips to speed claims processing
Part 1 – Employee
Missing or incomplete information will slow down claims processing. To
avoid this, please be sure to include:
#2 Patient birthdate
Helps identify an insured and determine dependent eligibility.
#6 Employee’s identification number
This is the most important identifier for the plan member.
#8 Student status
Because this information often changes, it is required on every claim
for dependents age 19 years and older.
#11 and #12 Coordination of benefits for dental
The “No” box under #11 should be checked if no other dental coverage
exists. If there is other dental coverage, the additional information
requested is necessary for coordination of benefits. This information is
required on every claim.
Part 2 – Dentist
Some dental claims require dental consultant review for accurate
processing. To help expedite the claims process, please be sure to
include:
#16 National Provider Identifier
There are two types of NPI. Type 1 is for individual providers who
operate independently. Type 2 is for health care providers such as
group practices or corporations including incorporated dental practices.
Type 2 organization providers may want their individual provider
employees to have Type 1 NPIs to distinguish them individually.
#17 and #24 Supporting Documentation
In addition to the following list, narratives or photos also may be
submitted. Documents should be dated and legible. Original radiographs
will be returned. Please label duplicate films left and right. All supporting
documentation should be current within one year. Procedure codes listed
are based on CDT © ADA.
• Pre-operative radiographs for D2510-D2664, D6600-D6634,
D2710-D2794, D6710-D6794, D6205-D6252, D2950, D6973,
D2952-D2954, D6970-D6972, D2960-D2962, D3346-D3348,
D3351-D3353 and D6010.
• Pre-operative radiographs and legible surgical notes for
D7210-D7241.
• Legible surgical notes only for D7310-D7321.
• Numerical 6-point periodontal charting for D4210-D4211,
D4240-D4241, D4341-D4342 and D4381.
#21 Prosthesis - Initial or Replacement
Required for crowns, onlays, bridges and partial or complete dentures.
If a replacement, prior placement date is needed.
#23 Statement of actual services, or Pretreatment estimate
Appropriate box should be marked to ensure correct handling.
#24 Tooth number, letter, quadrant or arch
Site-specific information is required using the Universal/National Tooth
Numbering System.
Pretreatment Estimate of Benefits
We recommend a pretreatment estimate of benefits when a plan
member considers the dental work to be expensive. A pretreatment
estimate lets both the member and dental provider know in advance
how much insurance will pay.
If dental coverage terminates for any reason during treatment, only
procedures performed before coverage ended will be eligible for payment.
For full information regarding coverage, plan members may refer to
their insurance plan booklet.
Website
Visit our website for benefit information, electronic forms, a dental
provider list and more. Please note, the free software Adobe Reader
®
(available through the internet) is needed to view and print the
electronic forms.
Electronic Claims and Attachments
Dental providers, with electronic claims we can process the same day
received and send a check within seven business days. Plus, most
software can submit claims and attachments while simultaneously
creating accounting records. For more information, please visit the
following websites:
• ndedic.org
• ez2000dental.com
• nea-fast.com
Fraud Warning Statements
Alabama: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or who knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to
restitution fines or confinement in prison, or any combination thereof.
Alaska: A person who knowingly and with intent to injure, defraud, or
deceive an insurance company files a claim containing false, incomplete, or
misleading information may be prosecuted under state law.
Arizona: For your protection Arizona law requires the following
statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject
to criminal and civil penalties.
Arkansas: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
California: For your protection California law requires the following to appear
on this form: Any person who knowingly presents 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.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado division of insurance within the department of
regulatory agencies.
Delaware: Any person who knowingly, and with intent to injure, defraud
or deceive any insurer, files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.
District of Columbia: WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding the insurer or any
other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to
a claim was provided by the applicant.
Florida: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the
third degree.
Georgia: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Idaho: Any person who knowingly, and with intent to defraud or deceive
any insurance company, files a statement or claim containing any false,
incomplete, or misleading information is guilty of a felony.
Indiana: A person who knowingly, and with intent to defraud an insurer
files a statement of claim containing any false, incomplete, or misleading
information commits a felony.
Kentucky: Any person who knowingly and with intent to defraud any
insurance company or other person files a statement of claim containing
any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Maine: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the
company. Penalties may include imprisonment, fines, or a denial of insurance
benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly or willfully presents
false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Minnesota: A person who files a claim with intent to defraud or helps
commit a fraud against an insurer is guilty of a crime.
Nebraska: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
New Hampshire: Any person who with a purpose to injure, defraud, or
deceive any insurance company, files a statement of claim containing any
false, incomplete, or misleading information is subject to prosecution and
punishment for insurance fraud, as provided by RSA 638.20
New Jersey: Any person who knowingly files a statement of claim containing
any false or misleading information is subject to criminal and civil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to civil fines
and criminal penalties.
New York: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals
for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime, and shall
also be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each such violation.
Ohio: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma: WARNING: Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Pennsylvania: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
Rhode Island: Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Tennessee: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment,  nes and denial of insurance bene ts.
Texas: 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.
Vermont: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Virginia: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Washington: It is a crime to knowingly provide false, incomplete, or
misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of
insurance benefits.
If you live in a state other than mentioned above, the following
statement applies to you: Any person who knowingly, and with intent
to injure, defraud or deceive any insurer or insurance company, files a
statement of claim containing any materially false, incomplete, or misleading
information or conceals any fact material thereto, may be guilty of a
fraudulent act, may be prosecuted under state law and may be subject to
civil and criminal penalties. In addition, any insurer or insurance company
may deny benefits if false information materially related to a claim is provided
by the claimant.
FA 32 Rev. 2-15 02-26-15
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Dental Claim Form (Orange County Community College)

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Completed 18 July 2020

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