42027 Dental Claim 8/29 - Arkansas Blue Cross and Blue Shield 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the header information. Mark all applicable transaction types in box 1, including 'Statement of Actual Services' or 'Request for Predetermination / Preauthorization'.
3. In the POLICYHOLDER/SUBSCRIBER INFORMATION section, provide the required details such as name, address, and policy number in boxes 2 and 12.
4. Next, complete the INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION section by entering the company name and address in box 3.
5. Fill out PATIENT INFORMATION by providing details about the patient’s relationship to the policyholder and their identification numbers in boxes 5 through 10.
6. Document services provided by entering procedure dates, tooth numbers, and fees in RECORD OF SERVICES PROVIDED from boxes 24 to 31.
7. Finally, ensure you sign where indicated for authorizations and submit your completed claim form to the specified address.

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