Member Dental Claim Form - CareFirst | Member Information · Address City State Zip Code: ......

MEMBER DENTAL CLAIM FORMPlease type or print

1. Identification Number 2. Group Number 3. Patients name (First, Middle Initial, Last)

4. Patients Date of Birth 5. Patients Sex 6. Patients Relationship to Subscriber:

Month Day Year Female c Self c Child c

_____/______/_____ Male c Spouse c Other c Explain:

7. Subscribers Name (First, Middle Initial, Last) 8. Daytime Telephone Number (include Area Code)

Subscribers Address (Street and Apt. or Box Number)

City State Zip Code

9. Is the patient covered under other dental insurance?

No c Yes c

If yes, name of insurance: _____________________________

Name of Policy Holder _________________________________

Other Policy ID Number ________________________________

10. Was patients condition due to:

Work related accident? No c Yes cAn auto accident? No c Yes cOther accidental injury? No c Yes c

If yes, give the date of accident _____/______/_____Mo. Day Year

Please attach a statement with details indicating when, where and the manner in which the injury occurred.

Was another party at fault? No c Yes c

11. ORTHODONTIA:

Is orthodontic treatment included in the services listed below?

No c Yes c

If yes, is this initial treatment? No c Yes c

Date appliance was placed: ______________________________________________________________________________

Expected completion date of orthodontic treatment: _________________________________________________________

Total charges for active treatment _________________________________________________________________________

12. 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 with CareFirst BlueCross BlueShield or CareFirst BlueChoice. I authorize any dentist or physician in possession of information concerning the patient to furnish such information to CareFirst BlueCross BlueShield or CareFirst BlueChoice upon request.

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.

______________________________________________________________________ _______________Signature of Subscriber or Spouse Date

CUT0167-1S (04/16)CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

13. CROWNS, BRIDGES AND DENTURES:

Do services include the replacement of prosthesis (crown, bridge, denture)? No c Yes c

If yes, what was the original prosthesis? Mo. Day Year Tooth Number(s)

Indicate date of original placement or restoration and original teeth involved: _____/______/______ ____________

Reason for replacement: Original Damaged c Lost or Stolen c Other c

(Explain) _______________________________________________________See item 17 of the instructions for X-ray requirements

14. ASSIGNMENT OF BENEFITS: (See instruction page.) The Plan may, at its discretion, accept or deny an assignment of benefits.

No c Yes c

If yes block above is marked, I authorize CareFirst BlueCross BlueShield or CareFirst BlueChoice to pay benefits directly to the provider of the services listed.

_____________________________________________________ ___________________Signature of Subscriber or Spouse Date

15. DESCRIPTION OF SERVICES (See instructions on reverse.)

Date of Service

A.D.A. Procedure Code

Detailed Description of Services Tooth No. or Letter

Surfaces # Times Perf.

Charge

M D Y

16. TOTAL CHARGES..............................................................................................................................................

17. ARE X-RAYS ENCLOSED?

No c Yes c (See Instructions page.)

18. PLEASE CHECK APPROPRIATE BOX

c ESTIMATE OF ELIGIBLE BENEFITSThe treatment listed is necessary in my professional judgement and I request an Estimate of Eligible Benefits.NOTE: Dentists Tax ID Number or Social Security Number is required

c WORK COMPLETED PAYMENT REQUESTEDI certify that the above services have been performed by me or under my personal supervision and are necessary in my professional judgement. Charges shown are my usual charges.

Dentists Signature Phone #

19.

Dentist Name c Tax ID No. or c SSN

Address City State Zip Code

MEMBER DENTAL CLAIM FORMInstructions

Use this claim form to submit a claim for services, which may be covered under your dental program. To avoid delay in having your claimprocessed, please complete a separate claim form for each patient, and ensure that all information is complete and correct. We will returnthe form to you for the information if each question is not answered. Items 1 through 19 of this form must be completed.

Item 1-19:Complete all items as indicated on the front form.

Item 9:Please check yes or no in item 9. If yes, please provide information regarding your other dental insurance coverage. If payment has beenreceived from another company, please attach a copy of their Explanation of Benefits.

Item 11:ORTHODONTIA - Claims for orthodontic services must include the information requested in item 14. It is not necessary for the orthodontictreatment to be completed before submitting the claim.

Item 13:CROWNS, BRIDGES, AND DENTURES - Please complete this information on any claim for a crown, bridge or denture. See item 17 below forX-ray requirements.

Item 14:ASSIGNMENT OF BENEFITS - Benefits for services provided by participating dentists are made payable directly to the dentist, whether ornot benefits are assigned. Benefits for services provided buy non-participating dentist located within our service area are made payabledirectly to the subscriber, regardless of any assignment of benefits (except for Virginia non-participating providers when benefits have beenassigned).

Item 15:DATE OF SERVICE - Month, day and year of services were rendered.ADA PROCEDURE CODES - Most recent American Dental Association codes.TOOTH NUMBERS - 1 to 32 for permanent dentition, A to T for primary (deciduous) dentition.SURFACES - Use the following codes to identify tooth surfaces: B = Buccal or facial D = Distal O = Occlusal M = Mesial I = IncisalL = LingualCHARGE - Indicate the individual charge for each service listed.

Item 17:X-rays are needed to review claims for posts and cores following root canals. Pre-operative X-rays are required for review of claims forcrowns and bridges. For periodontal procedures, we need the mot recent pre-operative X-rays and complete periodontal charting of theteeth involved in the treatment. We may also occasionally request X-rays for certain other procedures. All X-rays will be returned to thedentist after the claim has been reviewed. To expedite the processing of your claim and assist us in the return of the X-rays, please includethe patients name and identification number as well as the dentists name and address on the X-ray envelope.

Item 18:DENTISTS CERTIFICATION AREA Please check the appropriate box to indicate whether the services listed have been completed. Thedentists 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 availablefor the services listed. The estimates are based on the information we have at the time the claim is reviewed. Estimates will be subject toeligibility, deductibles, and Plan maximums. Therefore, they may be affected by other payments made between the time the estimate isgiven 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 an Estimate of Eligible Benefits, mark the Estimate of Eligible benefits box in item 18. In addition, the dentists address,and Tax ID Number or Social Security Number must be clearly written in item 19 of this claim form.

Item 19:Each claim must include a bill (on letterhead stationary) with the dentists name, address and Tax Identification Number or Social SecurityNumber. Please also check the appropriate box in item 19 to indicate the type of identification number used. Please keep copies; billscannot be returned.

When the claim form has been completed and signed, please mail it to:

Mail AdministratorP.O. Box 14115Lexington, KY 40512-4115

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820

Mailing Address P.O. Box 8894 Baltimore, Maryland 21224

Fax Number 410-505-2011

Email Address [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html



Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

855-258-6518 0

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gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

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ke ni wuu mu za.

(Bengali) : 855-258-6518 0

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(Traditional Chinese)

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Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

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