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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST A Nonprofit Corporation Kaiser Permanent Individuals and Families Dental Plan Evidence of Coverage Face Sheet Shown below are the Premium amounts referenced
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Specify the type of insurance you have, whether it is 2024 kp or dental, and provide your insurance policy number.
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Indicate the date of service or treatment for which you are seeking coverage.
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Describe the medical/dental procedure or treatment received in detail, including the diagnosis, codes, and any additional information required.
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Attach any supporting documents, such as invoices, receipts, or treatment plans, if necessary.
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Submit the filled-out form to the appropriate insurance provider or dental office, either by mail, fax, or online.

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KP or Dental 80L is a form used to report dental services provided to beneficiaries under a managed care plan.
Dental service providers who have provided services under a managed care plan are required to file KP or Dental 80L.
KP or Dental 80L should be filled out with details of the dental services provided, including beneficiary information, date of service, procedure codes, and fees.
The purpose of KP or Dental 80L is to accurately report dental services provided under managed care plans for billing and reimbursement purposes.
Information such as beneficiary details, date of service, procedure codes, and fees must be reported on KP or Dental 80L.
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