42027 Dental Claim 8/29 - Arkansas Blue Cross and Blue Shield 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the HEADER INFORMATION section. Mark all applicable transaction types, including 'Statement of Actual Services' or 'Request for Predetermination/Preauthorization'.
3. In the POLICYHOLDER/SUBSCRIBER INFORMATION section, enter the policyholder's name, address, and predetermination number if available.
4. Complete the INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION with the company name and address. Ensure you provide the policyholder ID and date of birth.
5. Fill in PATIENT INFORMATION by providing details about the patient’s relationship to the policyholder, along with their personal information.
6. In RECORD OF SERVICES PROVIDED, document each procedure date, tooth numbers, procedure codes, and fees associated with dental services rendered.
7. Finally, review your entries for accuracy before signing in AUTHORIZATIONS to confirm your understanding of treatment plans and fees.

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