Dental PTE Claim Form

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Provider

Location:

TIN:

Patient

Date of Birth:

Subscriber ID:

PTE to Claim Submission

Provider Information

Dentist Name

Phone Number

Email Address

Treating Location

NPI (National Provider Identifier)

TIN (Tax Identification Number)

Patient Information

What type of dental transaction was this?

Statement of actual services

Group Number:

Date of Birth:

Subscriber ID:

Address:

Claim Information

Does the patient have additional insurance that applies to this claim? *

Yes

What type of additional insurance is this?

Dental Insurance

Medical Insurance

Insurance Company Name

Subscriber First Name

Subscriber Middle Initial

Subscriber Last Name

Subscriber Date of Birth

Relationship with patient

If the patient has an EOB (Explanation of Benefits) for this dental/medical visit, it will need to be added to this claim. Instructions on how to add the EOB are in the final section of this form.

Does this claim include EPSDT / Title XIX? *

Yes

Who should be reimbursed for this claim? *

Provider

Member

Cancel

Claim Information

To complete this section, you will need a copy of the patient’s bill or statement. You may need to enter procedure codes, locations, and fees for service, which can be found on the bill. View the list of possible information you may need to file this claim.

indicates required fields

Procedure

Select All

Bulk Actions

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Additional Claim Information

Missing Teeth

Separate multiple tooth numbers with a comma (1, 7, 16)

Other Remarks

Content is limited to 250 characters

Please include any non-dental procedure diagnosis codes, electronic digital attachment ID's, office discounts applied, or other comments.

Does this claim include orthodontics?

Yes

Does this claim include prosthesis (crown, bridge, or denture)?

Yes

Does this claim relate to an accident/injury/illness?

Yes

Upload Documents

To ensure timely processing of this claim, please upload documents associated with the patient’s procedure(s).

indicates required fields

Required Documents

Total Upload Space

0 MB

10 MB

Drag your .pdf, .png, .jpg, .jpeg, .txt, .tif, .tiff, .gif, or .bmp file here for single file upload

To upload multiple documents, hold down the CTRL button while selecting files.

Max. file size: 2MB each

Provider Narrative

Content is limited to 250 characters

Provider Narrative is included in an attachment

Attachment includes radiographs

Helpful Resources

National Standardized Dental Claim Utilization Review Guidelines (for Commercial Only) - Dental Utilization Review Guideline

National Standardized Dental Claim Review Guidelines (for Medicare Advantage Plans Only) - Dental Review Guideline

Review and Sign

Provider Information

Dentist Name

Phone Number

Email Address

Treating Location

NPI (National Provider Identifier)

TIN (Tax Identification Number)

Patient Information

What type of dental transaction was this?

Statement of actual services

Claim Information

Does the patient have additional insurance that applies to this claim?

Does this claim include EPSDT / Title XIX?

Who should be reimbursed for this claim?

Missing Teeth:

Other Remarks:

Does this claim include orthodontics?

Date Orthodontics Appliance was Placed:

Number of Months Patient Received/is Receiving Orthodontic Care:

Does this claim include prosthesis (crown, bridge, or denture)?

Date of Prior Placement:

Reason for Replacement:

Does this claim relate to an accident/injury/illness?

Type of Accident/Injury/Illness

Date of Accident/Injury/Illness

Uploaded Documents

Provider Narrative:

Fraud Notice

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Acknowledgment and Signature

I certify that the procedures indicated on this form are either in progress or have been completed. I understand that by putting my name in the field below, I am signing this form electronically.

indicates required fields

Provider Acknowledgment

The dentist or dental office has explained the dental treatment plan and costs to the patient or authorized representative. The office has a patient or authorized representative signature stating that the patient or authorized representative will be responsible for all charges for dental services and materials not paid by the patient’s dental benefit plan, unless the charges are not allowed by law. The patient or authorized representative has also agreed in writing that the dentist or dental office can use and disclose the patient’s protected heath information in order to process this claim.

Payment Acknowledgment

The dentist or dental office has a signature on file of the patient or authorized representative allowing direct payment to the dentist or dental office.

Provider’s Signature

Today’s Date

Submit