How to Submit Your Dental Claim: Step-by-Step Guide
If our practice is out-of-network with your insurance provider, we are not able to submit claims directly to your insurance company. In the past we submitted claims to out-of-network insurance providers on behalf of patients. However, persistent administrative issues from insurance companies—including lengthy payment holds and misrouted reimbursement checks—created unnecessary confusion and delays for our patients.
To streamline care and due to multiple patient complaints, we are no longer able to bill or correspond with out-of-network insurance carriers. We are happy to provide an itemized upon request so you can seek reimbursement directly from your insurer. You will pay for your appointment at the time of service, and then submit a claim to your provider so they can reimburse you. The reimbursement rates vary by insurance company. They each have their own rules.
This guide walks you through completing and submitting your claim form at home using the itemized receipt provided by our office.
Step 1: Gather Your Documents
Before you begin, gather the following items:
Insurance Claim Form: You can download and print this form from your dental insurance provider's website. (We have some links at the bottom of this blog)
Itemized Receipt: This is the document provided to you at the end of your visit.
Pen: Use blue or black ink.
Step 2: Complete the Form Line by Line
Most dental claim forms use a standard layout with numbered sections. Refer to your itemized receipt to fill in the required fields. Each form is different so our box numbers are approximate, but give you details to what the form is requesting.
Approximately Boxes 1 to 11: Policyholder Information This section requires details about the primary account holder on the insurance policy.
Write your full legal name.
Enter your home address and date of birth.
Provide your Member ID number, which is located on your insurance card.
Approximately Boxes 12 to 17: Patient Information This section covers the individual who received dental care.
If you were the patient, select the box labeled "Self."
If a family member received care, enter their full legal name and date of birth.
Approximately Boxes 24 to 41: Treatment Details Copy the information directly from your itemized receipt into these fields.
Date of Service: Enter the date of your visit.
Tooth Number: Enter the specific tooth number listed on your receipt, if applicable.
Procedure Code: Enter the four-digit CDT code listed next to each treatment.
Fee: Enter the exact dollar amount charged for each service.
Approximately Boxes 36 and 42: Signatures and Payment Authorization
Sign and date the form.
Locate the section titled "Authorize Payment to Patient" or "Subscriber." Sign or check this box to ensure your insurance company mails the reimbursement check directly to your address rather than to our office.
Approximately Boxes 43 to 58: Provider Information This section identifies our practice. All required information is printed on your receipt.
Enter our practice name, address, and phone number: [Insert Office Address and Phone Number].
Enter our practice's National Provider Identifier (NPI) and Tax ID number, which are listed on your receipt.
Step 3: Mail the Documents
Place your completed claim form and a copy of your itemized receipt in an envelope. Address the envelope to the claims department listed on the back of your insurance card, add proper postage, and send it by mail.
Here are some links that may leaad you to the claim form you need. Always check with your insurance company first as they may have changed their forms without letting us know.
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