Most dentists submit claims directly to the insurers; therefore, you do not need to supply Dental claim forms to your members. If a claim is incurred outside your province of residence, or inside the province where the dentist has required payment from the member, a Standard Dental Claim form should be obtained from the dentist providing the service. These forms are available in all dental offices.
If a dental treatment is expected to exceed $500, a treatment plan (pre-authorization) should be submitted to the insurer prior to services being performed. The treatment plan itemizes what is covered by the insurer allowing the member to know exactly how much of the treatment is covered and how much they will have to pay.
Claims should be submitted within 90 days after the end of the calendar year in which expenses were incurred. If coverage has been terminated, members have 90 days from their termination date to submit any eligible claims, or as defined in your Benefits Handbook(s).
Dental claims may be submitted on either the GroupHEALTH standard dental claim form, or on a dental claim form generated by dental offices. For proper validation of coverage and payment, all dental claims must be signed by the Dentist and the member.
- Basic dental claims may be submitted via EDI, fax, mail, or the claims payor Mobile App.
- Pre-authorized Major and Orthodontic claims must be submitted with a Standard Dental Claim Form, via fax or mail only.
- Note: Major and Orthodontic expenses over $500 must be pre-authorized.