Electronic Claims
BeneCare Dental Plans will accept claims, coordination of benefits, and predetermination submissions through the Ben-E-Claim electronic claims portal (click on the link at left for more information) or through claims clearinghouses. BeneCare’s clearinghouse payer ID is 23210. Contact your practice management software vendor for a software update if you are unable to use BeneCare’s payer ID number.

Paper Claims   Downloadable Claim Form
BeneCare Dental Plans will accept claims, coordination of benefits, and predetermination submissions on any American Dental Association standard claim form. All submissions should include the following:

Claim Submission Guidelines
The following information is required on all claims:

•The Subscriber’s social security number or Medicaid ID;

•The Patient’s Name, Date of Birth and relationship to the Subscriber;

•The Dentist’s name or Practice Name, Tax Identification Number or Social Security Number, and phone number;

•The American Dental Association procedure code number (CDT), treatment date (insert or completion), tooth number, tooth surface(s), fees, and a narrative or description of services as appropriate;

•The Member’s signature for release of information and/or assignment of benefits. Signature on file is acceptable;

•The Dentist’s signature.

Coordination of Benefits
In addition to above, the primary carrier’s explanation of benefits with the subscriber’s name, Social Security Number or Medicaid ID, and date of birth, the alternate carrier’s name, and an explanation of payment or denial (EOB) are required for processing coordination of benefits submissions.

Predeterminations
In addition to the information required for regular claims above, please submit the following additional information or attachments with the claim form as noted by procedure below;

ADA CDT Code Description Required Documentation
2510 - 2799, 2932, 2949 - 2962 Restorative Periapical X-Ray(s)
3310 - 3999 Endodontics Periapical X-Ray Series (Post-Operative For Root Canal)
4210 - 4999 Periodontics X-Ray Series & Periodontal Charting
5211 - 5281, 5820, 5821, 5860, 5861, 5999 Dentures X-Ray Series or Panorex
6010 - 6975 Bridges X-Ray Series & Chart Of Missing Teeth
7130 - 7999 Extractions / Oral Surgery FMX or Panorex
8000 - 8999 Orthodontics Initial Fee, Length of Treatment Plan, Total Case Fee
9110 Emergency Treatment Narrative
9220 - 9230, 9241, 9242 Anesthesia Narrative
9940 - 9952 Appliances Narrative

A predetermination certification is valid for one year from the completion of review. Should the patient select treatment from a provider other than that indicated on the original form, and the treatment plan remains the same, a new certification can be requested without a review from the consultants. If the treatment plans change, a subsequent review would be conducted.

 

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