Member Dental Claim Form - Highmark Blog
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1
2
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4MEMBER DENTAL CLAIM FORM
Please submit
HEADER INFORMATION
claim form to the address
1. Type of Transaction (Mark all applicable boxes)
provided on the patient/
member ID Card.
Statement of Actual Services
Request for Predetermination/Preauthorization
EPSDT / Title XIX
POLICYHOLDER/SUBSCRIBER INFORMATION
(For Insurance Company Named in #3)
2. Predetermination/Preauthorization Number
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Policyholder/Subscriber ID (SSN or ID#)
M
F
17. Employer Name
OTHER COVERAGE
16. Plan/Group Number
( Mark applicable box and complete 5-11. If none, leave blank. )
4. Dental?
Medical?
(if both, complete 5-11 for dental only.)
PATIENT INFORMATION
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
18. Relationship to Policyholder/Subscriber in #12 Above
19. Reserve For Future Use
Self
Spouse
Dependent Child
Other
6. Date of Birth (MM/DD/CCYY)
7. Gender
8. Policyholder/Subscriber ID (SSN or ID#)
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
M
F
9. Plan/Group Number
10. Patient’s Relationship to Person named in #5
Self
Spouse
Dependent
Other
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
21. Date of Birth (MM/DD/CCYY)
22. Gender
23. Patient ID/Account #
( Assigned by Dentist )
M
F
RECORD OF SERVICES PROVIDED
25. Area
26.
24. Procedure Date
27. Tooth Number(s)
28. Tooth
29. Procedure
29a. Diag.
29b.
30. Description
31. Fee
of Oral
Tooth
(MM/DD/CCYY)
or Letter(s)
Surface
Code
Pointer
Qty.
Cavity
System
1
2
3
4
5
31a. Other
33. Missing Teeth Information (Place an “X” on each missing tooth.)
34. Diagnosis Code List Qualifier
(ICD-9 = B; ICD-10 = AB)
Fee(s)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15 16
34a. Diagnosis Code(s)
A _______________
C ________________
32. Total Fee
32 31 30 29
28
27 26 25 24 23
22
21
20
19
18
17
(Primary diagnosis in “A”)
B _______________
D ________________
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
38. Place of Treatment
(e.g. 11=office; 22=O/P Hospital) 39. Enclosures (Y or N)
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
(Use “Place of Service Codes for Professional Claims”)
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting
all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (
)
MM/DD/CCYY
of my protected health information to carry out payment activities in connection with this claim.
No (Skip 41-42)
Yes (Complete 41-42)
42. Months of Treatment 43. Replacement of Prosthesis 44. Date of Prior Placement (
)
MM/DD/CCYY
X __________________________________________________________________
Remaining:
Patient/Guardian Signature
Date
No
Yes (
)
Complete 44
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to
45. Treatment Resulting from
the below named dentist or dental entity.
Occupational illness/injury
Auto accident
Other accident
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
X __________________________________________________________________
Subscriber Signature
Date
BILLING DENTIST OR DENTAL ENTITY
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
(Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber.)
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
48. Name, Address, City, State, Zip Code
X __________________________________________________________________
Signed (Treating Dentist)
Date
54. NPI
55. License Number
56. Address, City, State, Zip Code
56a. Provider
49. NPI
50. License Number
51. SSN or TIN
Specialty Code
52. Additional Provider ID
52a. Phone Number
57. Phone Number
58. Additional Provider ID
(
)
-
(
)
-
5730 (R10-16)
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