Member Dental Claim Form - CareFirst

Member Dental Claim FormSubmit this claim form for services which may be covered under your dental benefits. Complete a separate claim form for eachpatient and ensure all information is complete and accurate. All questions must be answered or the form will be returned toyou to for complete answers. Each claim must include a bill (on letterhead stationary) with the dentist’s name, address and TaxIdentification Number or Social Security Number. Please keep copies; bills cannot be returned.Return this form with required documentation to: Mail Administrator, P.O. Box 14115, Lexington, KY 40512-4115.PATIENT INFORMATIONName (First, Middle Initial, Last)Date of birth (mm/dd/yyyy)/Member IDGender/Group NumberRelationship to SubscriberMaleFemaleSelfSubscriber’s Name (First, Middle Initial, Last)SpouseChildOther:Daytime PhoneSubscriber’s Address (Street and Apt. or Box Number)CityStateZip CodeIs the patient covered under other dental insurance?YesNoWas patient’s condition due to:If yes, name of insurance:Work related accident?An auto accident?Other accidental injury?YesYesYesName of policy holder:If yes, give the date of accident / /Mo.Other policy ID number:NoNoNoDayYear lease attach a statement with details indicating when, wherePand the manner in which the injury occurred.If payment has been received from another company, pleaseattach a copy of their Explanation of Benefits.Was another party at fault?YesNoORTHODONTIAIs orthodontic treatment included in the services listed below?If yes, is this initial treatment?YesNoDate appliance was placed/YesNoExpected completion date of orthodontic treatment///Total charges for active treatment Note: It is not necessary for the orthodontic treatment to be completed before submitting the claim.CROWNS, BRIDGES AND DENTURES (See below for X-ray requirements)Do services include the replacement of prosthesis (crown, bridge, denture)?YesNoIf yes, what was the original prosthesis? (Indicate date of original placement or restoration and original teeth involved below)Reason for replacement:Original DamagedLost or StolenDate of original placement or restoration//OtherTooth Number(s)X-RAY REQUIREMENTS X-rays are required to review claims for posts andcores following root canals. X-rays may also be requested for certain otherprocedures.Note: All X-rays will be returned to the dentist after the claimhas been reviewed. To expedite the processing of your claimand assist us in the return of the X-rays, please include thepatient’s name and identification number as well as the dentist’sname and address on the X-ray envelope.Pre-operative X-rays are required for review of claimsfor crowns and bridges.For periodontal procedures, the most recent preoperative X-rays and complete periodontal charting ofthe teeth involved in the treatment is required.CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the businessname of CareFirst Advantage, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District of Columbia andMaryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). CareFirst of Maryland, Inc., GroupHospitalization and Medical Services, Inc., CareFirst Advantage, Inc., Trusted Health Plan (District of Columbia), Inc., CareFirst BlueChoice, Inc., First Care, Inc., and The Dental Network, Inc. are independent licensees ofthe Blue Cross and Blue Shield Association. BLUE CROSS , BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independentBlue Cross and Blue Shield Plans.1CUT0167-1E (12/20)

ASSIGNMENT OF BENEFITSBenefits for services provided by participating dentists are made payable directly to the dentist, whether or not benefits areassigned. Benefits for services provided by non-participating dentists located within our service area are made payable directlyto the subscriber, regardless of any assignment of benefits (except for Virginia non-participating providers when benefits havebeen assigned).I authorize CareFirst BlueCross BlueShield or CareFirst BlueChoice to pay benefits directly to the provider of the services listed.YesNoThe Plan may, at its discretion, accept or deny an assignment of benefitDescription of ServicesDATE SERVICESRENDEREDADA PROCEDURECODES*TOOTHNUMBER(S)**DETAILED DESCRIPTION OF SERVICESSURFACES***# OF TIMESPERFORMEDCHARGE// // // // // // // Total Charges * Most recent American Dental Association codes.** Tooth Numbers—1 to 32 for permanent dentition, A to T for primary (deciduous) dentition.*** Surfaces—Use the following codes to identify tooth surfaces: B Buccal or facial D Distal O Occlusal M Mesial I Incisal L LingualAre X-rays enclosed? (Refer to X-ray Requirements section)YesNoDENTIST CERTIFICATIONEstimate of Eligible BenefitsWork Completed—Payment Requested The treatment listed is necessary in my professionaljudgment and I request an Estimate of Eligible Benefits. I certify that the above services have been performed by meor under my personal supervision and are necessary in myprofessional judgment. Charges shown are my usual charges.If no dates of service are indicated on the claim, we will provide an estimate of the benefits available for the services listed.The estimates are based on the information we have at the time the claim is reviewed. Estimates will be subject to eligibility,deductibles, and Plan maximums. Therefore, they may be affected by other payments made between the time the estimate isgiven and the time that the services are rendered. Actual payments will be made in the order that the claims are received.Dentist’s NameTax ID No. or SSNTax ID No.Social Security NumberAddressCityStateDentist’s SignaturePhoneZip CodeSIGNATUREThis claim form must be signed, if not, it will be returned.I certify that the above information is correct and apply for benefits under my dental coverage with CareFirst BlueCross BlueShieldor CareFirst BlueChoice. I authorize any dentist or physician in possession of information concerning the patient to furnish suchinformation to CareFirst BlueCross BlueShield or CareFirst BlueChoice upon request.Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly orwillfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinementin prison.Signature of SubscriberDate2CUT0167-1E (12/20)

Notice of Nondiscrimination andAvailability of Language Assistance Services(UPDATED 8/5/19)CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of theircorporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on thebasis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat themdifferently because of race, color, national origin, age, disability or sex.CareFirst: Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languagesIf you need these services, please call 855-258-6518.If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basisof race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil RightsCoordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator isavailable to help you.To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinatoras indicated below. Please do not send payments, claims issues, or other documentation to this office.Civil Rights Coordinator, Corporate Office of Civil RightsMailing AddressP.O. Box 8894Baltimore, Maryland 21224Email ne NumberFax Number410-528-7820410-505-2011You can also file a civil rights complaint with the U.S. Department of Health and Human Services,Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 20201800-368-1019, 800-537-7697 (TDD)Complaint forms are available at First BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc.,Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross andBlue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the businessname of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross and Blue Shield and the Cross and Shield Symbols are registered service marks of theBlue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.