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Empire dental claim form 2026

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The document is a Dental Claim Form used to submit dental treatment claims to Empire BlueCross BlueShield. It requires detailed patient and employee information, including coverage details, treatment estimates, and authorization for payment. The form also includes sections for the dentist to complete regarding services rendered and fees charged. Additionally, it provides instructions for patients and dentists on how to fill out the form correctly, as well as a statement regarding insurance fraud.

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Click ‘Get Form’ to open the empire dental claim form in the editor.
Begin by checking one of the options in section 1 to indicate whether you are submitting a dentist fee treatment estimate or a dentist statement of actual services.
Fill in your prior authorization number and patient ID number as required in sections 2 and 4.
Provide your personal information, including name, relationship to employee, birth date, and coverage details in sections 5 through 10.
If applicable, indicate if the patient is covered by another dental plan in section 14 and complete sections 15 through 18 with the necessary details.
Ensure that the billing dentist completes their section accurately, including signature and license number.
Review all entries for accuracy before submitting. Use our platform’s features to save or share your completed form easily.

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Versions	Form popularity	Fillable & printable
2005	4.8 Satisfied (250 Votes)
2000	4.3 Satisfied (62 Votes)

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What is the mailing address for Ameritas Life Insurance Corporation dental claims?

Ameritas Life Insurance Corp. Group Claim Office / P.O. Box 82520 / Lincoln, NE 68501-2520 / Toll Free 800-487-5553 / Web ameritas.com Ameritas payer ID for electronic claims is 47009.

How to submit claim for Ameritas Dental Insurance?

Follow these steps to submit your claim Download and fill out the following form. Dental Group Claim Form. Submit form via mail. Include X-rays, if applicable. Group Claims. PO Box 82520. Lincoln, NE 68501-2520.

What is the timely filing limit for Ameritas Dental Claims?

How much time do I have to submit a claim? We recommend that claims be submitted as soon as possible, as dental plans have a timely filing clause. Unless otherwise noted in your certificate, active insured members must submit claims to us within 90 days of the date of service.

empire dental claim form

Empire dental claim form pdf Empire dental claim form online Empire Life (Dental Provider login) Empire Life login

What is the payor ID for Ameritas Dental Insurance?

our payer ID: 47009 Download a claim form.

How do I print an open dental claim?

Users can also double-click a claim in the grid to preview. Blank: Print a blank version of the default claim form. Print: To print specific claims, select them, then click Print. To print all claims marked as Paper, do not select any claims, then click Print.

What does it mean to submit a dental claim?

Whatever services you receive during your visit, your dentist will submit a claim form to your dental insurance company requesting payment for the services rendered. In simple words, a claim is the formal payment request submitted by your dental service provider to your dental insurer.

How do I submit a dental claim to Ameritas?

For more information on e-claim submission or to learn about additional electronic services available, visit ameritas.com or call toll free 800-487-5553 (800-659-5556 in New York) or email provider@ameritas.com.

Where do I mail Empire Blue Cross Blue Shield of New York claims?

Empire BlueCross BlueShield HealthPlus New York Claims, P.O. Box 61010 Virginia Beach, VA 23466-1010.