Electronic Claims

Use payor ID 23210 with Emdeon, DentalXChange and Renaissance.

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.

The following information is required on all claims:

  1. The Subscriber's ID;
  2. The Patient's Name, Date of Birth and relationship to the Subscriber;
  3. The Dentist's name or Practice Name, Tax Identification Number or Social Security Number, National Provider Identifier (NPI) and phone number;
  4. The American Dental Association procedure code number (CDT), treatment date, tooth number, tooth surface(s), doctor's fees, and a narrative or description of services as appropriate;
  5. The Member's signature for release of information and/or assignment of benefits. Signature on file is acceptable;
  6. The Dentist's signature.

In addition to above, the primary carrier's explanation of benefits with the subscriber's name, subscriber 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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