DENTAL CARE CLAIM INSTRUCTIONS
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DENTAL CARE CLAIM INSTRUCTIONS Dental claim forms are also available from your dental service provider. The insurance companies also accepts claims submitted on the BC Dental Association’s standard claim form. You may download this claim form from the Claim From [link to Claim Form section]section of this website. Mailed Claims To submit claims by mail to the insurance company, use the insurance company Dental Care Claim form or the Alberta Dental Association’s standard claim form. The dentist must complete Part 1 and the covered member must complete Part 2. Reimbursement will be made to the covered member unless the member has assigned benefits payable to the dentist (under Part 1 of the insurance company Dental Care Claim form). Orthodontic Claims Submissions If the dentist/orthodontist completes Part 1 and you complete Part 2 of the claim form, the insurance company does not require original receipts. Insurance company requires that original receipts for orthodontic claims be attached to your claim form if only Part 2 has been completed by you. Orthodontic services are typically not reimbursed unless the insurance company has a complete orthodontic treatment plan on file. Please see the section, Predeterminations, for more details. Electronic Claims Submissions insurance company encourages dental offices to submit claims using the Electronic Data Information (EDI) system. The EDI system automatically verifies eligibility, coverage amounts, and expedites reimbursement to the covered member or dentist. Assignment of Benefits If you would like payment to go directly to your service provider, complete the “Assignment of Benefits” portion of your claim form. Note: Check with your provider regarding his/her assignment of benefits policy first. Coordination of Benefits Claims If you have coverage under more than one benefit plan, you may be eligible for coordination of benefits. For more information on coordination of dental benefits, go to Understanding Coordination of Benefits for Dental Coverage. The Benefit Information Handbook also contains information on coordination of benefits. Information regarding coordination of benefits must be included with every claim. The following information must be included: • any other coverage held by spouse or dependent • name of other carrier • individual identification number(s) • an “Explanation of Benefits” from the other carrier Note: When submitting an “Explanation of Benefits” from another benefits carrier, please ensure that the statement is attached to a completed the insurance company Dental Care Claim form. Your coverage is always first-payer for yourself and your spouse’s carrier is your secondary coverage. The first-payer for your children is the carrier of the parent whose birthday comes first in a year (not necessarily the eldest). Example: If the father is born in January and the mother is born in March, all claims for children must be submitted to the father’s benefits carrier first. PREDETERMINATIONS A predetermination is a proposed course of treatment submitted to the insurance company by the dentist or orthodontist to determine allowable procedures, percentage of amount payable, and the maximum allowance for the calendar year. Note: Predeterminations only take into account the accumulated maximum at the time of authorization. On occasion, the insurance company may request pre-treatment X-rays or other information to support a treatment plan. Where two or more courses of treatment are submitted, reimbursement will be based on the least expensive of the proposed treatments. We recommend you submit a dental predetermination well in advance of any proposed treatment if the estimated cost is $500 or more. The portion of the dental expense covered by your Dental Care plan can be determined in advance and you will know the extent of your costs prior to treatment. Orthodontic Predeterminations Insurance companies do not typically reimburse for orthodontic appliances, bands or adjustments until the insurance company has provided their assessment of the predetermination. Your orthodontist must submit the following information: • an explanation of the proposed treatment program • a breakdown of estimated costs • anticipated length of time per course of treatment • the date the appliance was placed if prior to the effective date of dental coverage Predeterminations can be submitted on the insurance company’s Dental Care Claim form, the Dental Association’s standard claim form or by electronic submission. Mailed submissions should be clearly marked “predetermination.”
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