NC Preferred Health Plan of the Carolinas Dental Claim Form 2011-2025 free printable template

Dental Claim Form 1. Dentist s pre-treatment estimate Dentist s statement of actual service 2. Medicaid Claim EPSOM Patient Name (last, first, middle) Specialty Preferred Health Plan of the Carolina's

How to fill out NC Preferred Health Plan of form Carolinas

How to fill out NC Preferred Health Plan of the Carolinas Dental Claim

1. Obtain the NC Preferred Health Plan of the Carolinas Dental Claim form from the official website or your dentist's office.
2. Fill in your personal information at the top of the form, including your name, address, and member identification number.
3. Provide the provider's information, including the dentist's name and address.
4. Detail the treatment received by specifying the procedure codes and descriptions as required.
5. Include the date of service for each procedure.
6. List the total charges for each procedure along with any payments made at the time of service.
7. Sign and date the claim form to verify that all the information is accurate and complete.
8. Submit the completed claim form to the appropriate claims address provided in the instructions, either by mail or electronically.

Who needs NC Preferred Health Plan of the Carolinas Dental Claim?

1. Individuals enrolled in the NC Preferred Health Plan of the Carolinas who have received dental services and wish to file a claim for reimbursement.
2. Patients seeking coverage for dental treatments that are eligible under their plan.

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What is NC Preferred Health Plan of the Carolinas Dental Claim?

The NC Preferred Health Plan of the Carolinas Dental Claim is a form used to request reimbursement for dental services provided to beneficiaries of the NC Preferred Health Plan.

Who is required to file NC Preferred Health Plan of the Carolinas Dental Claim?

Dental providers who offer services to patients covered under the NC Preferred Health Plan are required to file the claims for reimbursement.

How to fill out NC Preferred Health Plan of the Carolinas Dental Claim?

To fill out the claim, providers must complete all required sections of the claim form, including patient information, service details, and billing codes, and then submit it to the appropriate billing address.

What is the purpose of NC Preferred Health Plan of the Carolinas Dental Claim?

The purpose of the claim is to facilitate the process of obtaining reimbursement for dental services rendered to eligible patients under the NC Preferred Health Plan.

What information must be reported on NC Preferred Health Plan of the Carolinas Dental Claim?

The claim must report patient demographics, provider details, a description of services rendered, procedure codes, dates of service, and any applicable charges.