WA ADA Guardian Dental Claim Form J400 2006-2025 free printable template

Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPS DT/ Title XIX 2. Predetermination / Preauthorization Number Request for Predetermination

How to fill out guardian claim forms

How to fill out WA ADA Guardian Dental Claim Form J400

1. Obtain the WA ADA Guardian Dental Claim Form J400 from the ADA website or your dental office.
2. Fill in the patient's personal information including name, address, and policy number.
3. Provide the dentist's information including their name, address, and provider number.
4. Detail the services provided including dates of service and codes for the treatment.
5. Include the patient's signature and date to authorize the release of information.
6. Attach any required documents such as itemized bills or pre-treatment estimates.
7. Double-check all information for accuracy and completeness.
8. Mail the completed form to the address provided on the form.

Who needs WA ADA Guardian Dental Claim Form J400?

1. Patients who have received dental services covered by Guardian insurance.
2. Dentists submitting claims on behalf of their patients.
3. Patients seeking reimbursement for out-of-pocket dental expenses.

People Also Ask about guardian dental appeal form

How do I submit a dental claim to my guardian?

To file a Dental claim electronically, follow these steps. Log into Guardian Anytime. Select Contact us/Secure channel (located in the page footer). Click on Customer Service Request, then click on Dental and fill in all required information. Attach the completed claim form and other documents to upload. Click Submit.

What is Guardian Dental Insurance phone number?

To file a Dental claim electronically, follow these steps. Log into Guardian Anytime. Select Contact us/Secure channel (located in the page footer). Click on Customer Service Request, then click on Dental and fill in all required information. Attach the completed claim form and other documents to upload. Click Submit.

How do I create a guardian account?

How to register for a Guardian Anytime account Go to our self-registration page and choose Member as your User Role. Note: If you are registering as a dependent, you'll need the employee's member ID, last name, date of birth and company name. Create a username and password, click Submit, and you're done.

Does Guardian Insurance have an app?

On the app and website, you can: Get 24/7 access to your Guardian accounts and policies. Opt to receive statements electronically. Make premium payments and pay off loans.

How do I find my Guardian membership number?

Your member ID number is a unique identifier that helps protect your identity and can be found in the following places: On the secure member service site. Login here. On your welcome letter. On your ID card. By calling 1-844-561-5600 to speak to one of our customer service representatives.

How do I set up a guardian dental account?

Follow these simple steps Go to our self-registration page and choose Member as your User Role. Note: If you are registering as a dependent, you'll need the employee's member ID, last name, date of birth and company name. Create a username and password, click Submit, and you're done.

How do I submit a claim to Guardian Dental?

To file a Dental claim electronically, follow these steps. Log into Guardian Anytime. Select Contact us/Secure channel (located in the page footer). Click on Customer Service Request, then click on Dental and fill in all required information. Attach the completed claim form and other documents to upload. Click Submit.

What is the payer ID CX078?

Anthem Blue Cross (Payer ID 47198) Direct to Consumer (Premier) (Payer ID CX078) California State Government (Payer ID CPPCA)

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What is WA ADA Guardian Dental Claim Form J400?

The WA ADA Guardian Dental Claim Form J400 is a standardized form used by dental providers to submit claims for reimbursement from Guardian Insurance for dental services rendered to patients.

Who is required to file WA ADA Guardian Dental Claim Form J400?

Dental providers who are enrolled in the Guardian Insurance network and have rendered services to patients with Guardian coverage are required to file this form for reimbursement.

How to fill out WA ADA Guardian Dental Claim Form J400?

To fill out the WA ADA Guardian Dental Claim Form J400, providers must complete sections including patient information, provider details, services rendered, and any necessary billing codes, ensuring all required fields are accurately filled.

What is the purpose of WA ADA Guardian Dental Claim Form J400?

The purpose of the WA ADA Guardian Dental Claim Form J400 is to submit dental claims to Guardian Insurance for payment for covered dental procedures performed by providers.

What information must be reported on WA ADA Guardian Dental Claim Form J400?

The information that must be reported includes patient demographics, provider identification, diagnosis codes, procedure codes, dates of service, and any relevant treatment notes.