Form Gc-8 - Aetna Dental Benefits Forma - Claim Instructions printable pdf download

Dental Benefits – Claim Instructions

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 claim

was provided by the applicant.

California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud

or deceive any insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a

crime and may be subject to fines, confinement in a state prison and substantial civil penalties.

Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding

insurance proceeds must be reported to the Insurance Division.

Pennsylvania Residents: 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.

NOTE: INCOMPLETE CLAIM FORMS WILL BE RETURNED TO YOU FOR MISSING INFORMATION. THIS WILL

DELAY THE PROCESSING OF THE CLAIM. FOR FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY

CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION REGARDING ELECTRONIC CLAIM

SUBMISSIONS.

TO THE EMPLOYEE

1. Complete items one (1) through twenty-two (22) in full.

2. Complete items 23 – 27 only if other dental coverage exists.

3. Be certain to sign the authorization to release information block (28).

4. If you wish to have your benefits for this claim paid directly to your dentist, sign the block (29).

If total charges for the planned course of treatment are expected to exceed the minimum Predetermination dollar amount stated in

your dental plan booklet, it is suggested you file for Predetermination of Benefits. Aetna Dental™ will notify your dentist of the

benefits payable.

NOTE: YOUR DENTAL COVERAGE IS SUBJECT TO SPECIFIC LIMITATIONS AND EXCLUSIONS. PLEASE REFER TO

YOUR DENTAL BOOKLET FOR DESCRIPTION OF COVERED EXPENSES, DEDUCTIBLE AND COPAYMENT

INFORMATION, AND LIMITATIONS AND EXCLUSIONS.

TO THE DENTIST

1. COMPLETED SERVICES ⎯ Check the box noted "STATEMENT OF SERVICES RENDERED" and complete items 30 through

46. When entering the treatment plan on the form, please indicate a separate fee for each individual service rendered.

2. PREDETERMINATION OF BENEFITS ⎯ If total charges for this claim are to exceed the minimum Predetermination dollar

amount indicated in the employee's Dental Plan Booklet (and treatment is not emergency in nature), Predetermination of Benefits is

suggested. Check the box marked "PRE-TREATMENT ESTIMATE", and complete items 30 through 46.

NOTE: PREDETERMINATION OF BENEFITS IS ONLY INTENDED TO AVOID MISUNDERSTANDINGS BETWEEN THE

EMPLOYEE, DENTIST AND INSURANCE COMPANY CONCERNING BENEFITS PAYABLE. YOU AND YOUR PATIENT

ARE, OF COURSE, FREE TO PURSUE ANY TREATMENT PLAN YOU THINK BEST.

3. If the employee indicates that benefits should be paid directly to the dentist, then these benefits will be sent directly to you with an

information copy of the transactions to the employee.

*X-rays taken for metal restorations and crowns should be submitted with treatment plan. They may also be requested for other

services. X-rays will be reviewed by practicing Dentists and returned promptly.

TO THE EMPLOYEE & DENTIST

Send the completed benefits request and the bills to the Aetna Dental™ office that services your employer

R-POD

GC-8 (11-04)

Form Gc-8 - Aetna Dental Benefits Forma - Claim Instructions