Healthplex Claim Form For All Groups Administered

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Send Completed Forms to: Healthplex, Inc.
Attention: Claims Dept.
PO Box 9255
For All Groups Administered by Healthplex
Uniondale, NY 11553-9255
Fax: 516-542-2614
HEADER INFORMATION
Providers Call – (888) 468-2183 Press
on 1 for IVR or
on 3
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination/Preauthorization
ALL INFORMATION MUST BE PRINTED
EPSDT/Title XIX
2. Predetermination/Preauthorization Number
(For Insurance Company Named in #3)
POLICYHOLDER/MEMBER INFORMATION
12. Policyholder/Member Name (Last, 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/YYYY)
14. Gender
M
F
OTHER COVERAGE
16. Plan/Group Number
(Mark applicable box and complete items 5-11. If none, leave blank.)
17. Employer Name/Group Name
4.
(If both complete 5-11 for dental only)
Medical?
Dental?
5. Name of Policyholder/Member in #4 (Last, First, Middle Initial, Suffix)
PATIENT INFORMATION
18. Relationship to Policyholder/Member in #12 Above
19. Reserved For Future Use
6. Date of Birth (MM/DD/YYYY)
7. Gender
Self
Spouse
Other
8. Policyholder/Member ID (SSN or ID#)
Dependent Child
M
F
20. Name (Last, First, Middle Initial, Suffix) Address, City, State, Zip Code
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/YYYY)
22. Gender
M
F
RECORD OF SERVICES PROVIDED - TO BE COMPLETED BY DENTIST
28.
29.
24.
25.
26.
27.
29a.
29b.
30.
31.
Fee
Procedure Date
Area of
Tooth
Description
Tooth Number(s)
Tooth
Procedure
Diagnostic
Quantity
Surface
Code
(MM/DD/YYYY)
Oral Cavity
System
or Letter(s)
Pointer
1
2
3
4
5
6
7
8
9
10.
33. Missing Teeth Information (Place an “X” on
each missing tooth)
34. Diagnosis Code List Qualifier
(ICD-9 = BB; ICD-10 = AB)
31a. Other
Fee(s)
1
2
3
4
5
6
7
8
9
10 11
12
13 14
15 16
A
C
34a. Diagnosis Codes
(Primary diagnosis in “A”)
Total Fee
32 31 30 29 28
27 26 25
24
23 22
21 20 19 18 17
32.
B
D
35. Remarks
ANCILLARY CLAIM TREATMENT INFORMATION
AUTHORIZATIONS
36. I have been informed of the treatment plans and associated fees. I agree to be responsible for all
39. Enclosures?
38. Place of Treatment
(e.g 11 = Office; 22 = O/P Hospital)
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
No
Yes
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting
(Use “Place of Service Codes for Professional Claims”)
all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
of my protected health information to carry out payment activities in connection with this claim. I
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/YYYY)
understand that benefits will automatically be assigned to my dentist if he or she is a Healthplex
Participating Provider.
No (Skip 41-42)
41-42)
Yes (Complete
X
.
_________________________________________________________________________________
42. Months of Treatment
43
Replacement of Prosthesis
44. Date of Prior Placement (MM/DD/YYYY)
Signed (Patient or Member/Guardian)
Date
No
Yes
(Complete 44)
___________________________________________________________________________________
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly
45. Treatment Resulting from (check applicable box)
to the below named dentist or dental entity, if allowed under my group guidelines. I understand that
benefits will automatically be assigned to my dentist if he or she is a Healthplex Participating Provider.
Occupational Illness/Injury
Auto Accident
Other Accident
X
46. Date of Accident (MM/DD/YYYY)
47. Auto Accident State
_________________________________________________________________________________
Signed (Member/Guardian)
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/member)
53.
I hereby certify that the procedure(s) as indicated by date are in progress (for procedures that require multiple
visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect
48.
Name, Address, City, State, Zip Code
for those procedures.
X
_____________________________________________________________________________________________
Signed (Treating Dentist)
Date
_______________________________________________________________________________________________
54. NPI
55. License Number
___________________________________________________________________________________
_______________________________________________________________________________________________
49. NPI#
50. License Number
51. SSN or TIN
56. Address, City, State, Zip Code
56a. Specialty Provider Code
___________________________________________________________________________________
_______________________________________________________________________________________________
52. Phone Number
52A. Additional Provider ID
57. Phone Number
58. Additional Provider ID
F-2203
Rev. 01/15
Print 03/16

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