Humana dental claim form 2025

1. Click ‘Get Form’ to open the Humana Dental Claim Form in the editor.
2. Begin by filling out the header information. Indicate the type of transaction by marking the applicable boxes, and provide your predetermination/preauthorization number if available.
3. Next, enter the subscriber's name, address, and contact details. Ensure that you accurately fill in the insurance company or dental benefit plan information.
4. If there is other dental or medical coverage, select 'Yes' and complete sections 5-11 with the policyholder's details, including their date of birth and gender.
5. Proceed to patient information. Fill in the patient's relationship to the policyholder, name, address, date of birth, and gender.
6. In the record of services provided section, document each procedure date along with relevant details such as tooth numbers and fees for each service rendered.
7. Complete any missing teeth information by placing an 'X' on each missing tooth as indicated on the form.
8. Finally, ensure all signatures are obtained from both patient and subscriber before submitting your claim.

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