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2006 ada dental claim form

Geha dental claim form 2025

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24 votes

The document is a Dental Claim Form used for submitting dental service claims to insurance companies or dental benefit plans. It includes sections for header information, policyholder and patient details, record of services provided, authorizations, and billing dentist information. The form requires completion of various fields related to the patient's insurance coverage, treatment details, and provider information. Additionally, it provides instructions for proper completion and submission of the form.

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Click ‘Get Form’ to open the GEHA Dental Claim Form in the editor.
Begin by filling out the header information, including your transaction type. Mark applicable boxes for services rendered or preauthorization requests.
In the Policyholder/Subscriber Information section, enter your name, address, and policy details accurately. Ensure that all required fields are completed.
Provide patient information next. Specify the relationship to the policyholder and include relevant identification numbers.
Record services provided by entering procedure dates, tooth numbers, and associated fees in the designated sections.
Complete any missing teeth information if applicable, marking each missing tooth clearly.
Finally, review all entries for accuracy before signing and submitting your claim. Use our platform’s features to save or share your completed form easily.

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Versions	Form popularity	Fillable & printable
2019	4.6 Satisfied (43 Votes)
2006	4.3 Satisfied (24 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long do I have to submit a dental insurance claim?

Each insurance provider sets its own filing deadline, which can range from 90 days to 12 months from the date of service. For example, some private insurers may have a 90- to 180-day window, while many PPOs and HMOs allow 6 to 12 months for claim submission.

How to file a dental claim?

How to file a claim Dentists name, address and phone number. Date each service was performed. Description, procedure code and fee for each service performed. List of affected teeth. Total cost of services performed. Dentists National Provider Identifier (NPI) Dentists Tax Identification Number (TIN) State license number.

Does geha cover dental?

G.E.H.A has a dental plan designed for you. Our high dental plan offers maximum dental coverage for people expecting dental procedures. Enjoy no in- or out-of-network deductible and an unlimited annual benefit maximum with three cleanings per year.

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