Get the free Blue Shield Dental Claim Form - Questar III - questar

Dental Claim Form BLUE SHIELD OF NORTHEASTERN NEW YORK PO BOX 80 BUFFALO, NY 14240 See reverse for instructions 2 1 o Medicaid Claim o EPSOM o Dentist's pre-treatment estimate o Dentist's statement

How to fill out blue shield dental claim

How to fill out blue shield dental claim:

1. Obtain the necessary claim form from Blue Shield or download it from their website.
2. Fill in your personal information, including your name, address, and phone number.
3. Provide your Blue Shield member ID and group number.
4. Indicate the patient's information, including their name and date of birth.
5. Include the date of service for the dental treatment or procedure.
6. Specify the dental provider's name, address, and phone number.
7. Describe the dental services rendered or procedures performed, including any applicable procedure codes.
8. Include the diagnosis codes associated with the dental treatment.
9. Fill in the charges for each dental service or procedure.
10. Indicate any applicable dental insurance coverage and include the amount paid by Blue Shield.
11. Attach any necessary supporting documentation, such as itemized bills or x-rays.
12. Review the completed claim form for accuracy and completeness.
13. Mail the claim form to the address provided by Blue Shield for dental claims.

Who needs blue shield dental claim:

1. Individuals who have dental insurance coverage through Blue Shield.
2. Patients who have received dental treatment or services from a dental provider within the Blue Shield network.
3. Anyone seeking reimbursement for eligible dental expenses covered by Blue Shield.

For pdfFiller’s FAQs

What is blue shield dental claim?

Blue Shield dental claim is a statement of services provided by a dentist that is submitted to Blue Shield for reimbursement.

Who is required to file blue shield dental claim?

Dentists or dental offices are required to file Blue Shield dental claims for services rendered to patients with Blue Shield insurance.

How to fill out blue shield dental claim?

Blue Shield dental claims can be filled out online or on paper forms provided by Blue Shield. Dentists must provide details of the services rendered, patient information, and any supporting documentation.

What is the purpose of blue shield dental claim?

The purpose of Blue Shield dental claim is to request reimbursement from Blue Shield for dental services provided to patients with Blue Shield insurance.

What information must be reported on blue shield dental claim?

Information such as the patient's name, date of birth, insurance policy number, details of the services provided, dates of service, and the dentist's information must be reported on Blue Shield dental claim.

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