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How to use or fill out MEDICAL PRE-TREATMENT ESTIMATE FORM
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Click ‘Get Form’ to open it in the editor.
Begin by filling out the employee information section. Clearly print your name, Social Security Number or Alternate ID, email (optional), date of birth, mailing address, and phone number.
Next, provide the patient’s details including their name and date of birth.
In the 'FOR COMPLETION BY PROVIDER' section, ask your healthcare provider to fill in their name, phone number, address, email, proposed treatment date, and whether inpatient services are required.
Your provider should then list the primary and secondary diagnosis codes along with a description of the treatment and associated CPT codes with estimated charges for each procedure.
Finally, ensure that your provider signs off on the estimate before submitting it to the ASEA Health Trust Administrator at the provided address.
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Healthcare providers share the estimate with the patient. The estimate includes what the patient must pay, insurance coverage, and out-of-pocket expenses. Providers may also explain the payment options.
Is a pre-treatment estimate a bill?
A Pre-Treatment Estimation of Benefits, however, is not a guarantee of payment, as received treatment claims are based on current eligibility and contract benefits in effect at the time of the completed service.
What is a pretreatment estimate?
Call the doctors office or their network phone number. Ask to speak to billing and they should be able to give an estimate based on your insurance.
What is a pre-treatment estimate?
Pre-treatment estimates help members understand and manage their costs by breaking down complex procedures into easy-to-understand, itemized lists. They show what portion of a bill is paid by the patient and what portion will be paid by their dental plan.
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Step 1. You request a pre-treatment estimate from your dentist. Step 2. Your dentist sends Delta Dental a proposed treatment plan and x-rays, if necessary.
Request Form: Documentation for Treatment Limitations
You can use this form to request general information about treatment limitations or specific information about limitations that may have resulted in denial of.
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