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Dental Claim Filing Instructions

Please read the following before downloading the form:

  • Pre-certification is required for all crown, bridge, prosthetic, orthodontic, and periodontal procedures. Providers must obtain written approval from the Plan before initiating any procedures where pre-certification is required.

  • X-rays must be submitted with all claims when requesting pre-certification.

  • Study models or diagnostic photos are required for all orthodontic claims.

  • Periodontal charting is required for all periodontal claims.

Download form.