Confidential Dental Claim Form
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1Dental Claim Form
-- Confidential --
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination / Preauthorization
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association
®Registered Marks of the BlueCross BlueShield Association, an Association of Independent BlueCross BlueShield Plans
EPSDT/ Title XIX
2. Predetermination / Preauthorization Number
POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)
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
BlueCross BlueShield of Tennessee
Claims Service Center
1 Cameron Hill Circle Suite 0002
14. Gender
15. Subscriber Identification Number
13. Date of Birth (MM/DD/CCYY)
Chattanooga,TN 37402-0002
M
F
OTHER COVERAGE
16. Plan/Group Number
17. Employer Name
4. Other Dental or Medical Coverage?
No (Skip 5-11)
Yes (Complete 5-11)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
PATIENT INFORMATION
18. Relationship to Policyholder/Subscriber in #12 Above
19. Student Status
8. Subscriber Identification Number
Self
Spouse
FTS
PTS
6. Date of Birth (MM/DD/CCYY)
7. Gender
Dependent Child
Other
M
F
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
10. Patient’ s Relationship to Person Named in #5
9. Plan/Group Number
Self
Spouse
Dependent
Other
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
22. Gender
23. Patient ID/Account # (Assigned by Dentist)
21. Date of Birth (MM/DD/CCYY)
M
F
RECORD OF SERVICES PROVIDED
25. Area
26.
24. Procedure Date
27. Tooth Number(s)
28. Tooth
29. Procedure
of Oral
Tooth
30. Description
31. Fee
or Letter(s)
(MM/DD/CCYY)
Surface
Code
Cavity
System
1
2
3
4
5
6
7
8
9
10
MISSING TEETH INFORMATION
Permanent
Primary
32. Other
Fee(s)
1
2
3
4
5
6
7
8
9
10
11
1 2
13
14
15
16
A
B
C
D
E
F
G
H
I
J
34. (Place an 'X' on each missing tooth)
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
33.Total Fee
O
N
M
L
K
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
39. Number of Enclosures (00 to 99)
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
38. Place of Treatment
Radiograph(s)
Oral Image(s)
Model(s)
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or
the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of
Provider’s Office
Hospital
ECF
Other
such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
information to carry out payment activities in connection with this claim.
No (Skip 41-42)
Yes (Complete 41-42)
X
44. Date Prior Placement (MM/DD/CCYY)
Patient /Guardian signature
42. Months of Treatment
43. Replacement of Prosthesis?
Date
Remaining
No
Yes (Complete 44)
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named
dentist or dental entity.
45. Treatment Resulting from
Occupational illness / injury
Auto accident
Other accident
X
Subscriber signature
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
Date
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
BILLING DENTIST OR DENTAL ENTITY
(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
56A. Provider
56. Address, City, State, Zip Code
Specialty Code
49. NPI
50. License Number
51. SSN or TIN
57. Phone
52. Phone
52A. Additional
58. Additional
(
)
–
(
)
–
Number
Provider ID
Number
Provider ID
Dental Claim Form 01.2008
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