Humana Dental Form – Fill Out and Use This PDF

The Humana Dental form, also known as the Dental Claim Form, is a comprehensive document designed for patients to claim dental benefits or preauthorize dental procedures. It includes various sections such as policyholder information, dental benefit plan details, patient details, other coverage, record of services provided, and authorizations. For those seeking to utilize their dental benefits effectively, completing the Humana Dental form accurately is pivotal. Click the button below to start filling out your form.

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Humana Dental Form PDF Details

Making sense of the Humana Dental Claim Form can seem overwhelming at first glance, but understanding its sections and requirements is crucial for a smooth claim process. This form serves multiple purposes, including the submission of actual services rendered and requests for predetermination/preauthorization of dental treatments, catering to both the policyholder's and the dental provider's needs. It requires detailed information about the policyholder and patient, including their relationships, identification numbers, and coverage details. It also encompasses dental benefit plan information, ensuring that all parties involved—the insurance company, the dental practice, and the patient—are on the same page regarding the services provided and the coverage available. Additionally, the form is designed to capture detailed records of dental services, including procedure dates, teeth affected, and the treatment performed, facilitating accurate claim assessment and processing. Other critical sections of the form address other insurance coverage, diagnoses, place of treatment, and authorizations, all aimed at streamlining the claim process. Key elements like gender codes and treatment places adhere to standard coding systems, ensuring consistency and compliance across dental practices and insurance carriers. The form's design, which fits a standard #9 window envelope, and the comprehensive instructions provided by the American Dental Association (ADA) further ease the submission process. By carefully completing the Humana Dental Claim Form, patients and dental providers can ensure accurate and timely handling of dental insurance claims.

Question	Answer
Form Name	Humana Dental Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	humana ada dental claim form, humana dental reimbursement form, humana form ada dental claim, humana dental forms

Form Preview Example

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Dental Claim Form

HEADER INFORMATION

1. Type of Transaction (Mark all applicable boxes)

Statement of Actual Services

Request for Predetermination/Preauthorization

EPSDT / Title XIX

2. Predetermination/Preauthorization Number

POLICYHOLDER/SUBSCRIBER INFORMATION (Assigned by Plan Named in #3)

12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

DENTAL BENEFIT PLAN INFORMATION

3. Company/Plan Name, Address, City, State, Zip Code

13. Date of Birth (MM/DD/CCYY)

14. Gender

15. Policyholder/Subscriber ID (Assigned by Plan)

OTHER COVERAGE (Mark applicable box and complete items 5-11. If none, leave blank.)

16. Plan/Group Number

17. Employer Name

4. Dental?

Medical?

(If both, complete 5-11 for dental only.)

5. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Suffix)

PATIENT INFORMATION

18. Relationship to Policyholder/Subscriber in #12 Above

19. Reserved For Future

Self

Spouse

Dependent Child

Other

Use

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6. Date of Birth (MM/DD/CCYY)

7. Gender

8. Policyholder/Subscriber ID (Assigned by Plan)

20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

9. Plan/Group Number

10. Patient’s Relationship to Person named in #5

Self

Spouse

Dependent

Other

11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code

21. Date of Birth (MM/DD/CCYY)

22. Gender

23. Patient ID/Account # (Assigned by Dentist)

RECORD OF SERVICES PROVIDED

24. Procedure Date

25. Area

26.

27. Tooth Number(s)

28. Tooth

29. Procedure

29a. Diag.

29b.

of Oral

Tooth

30. Description

31. Fee

(MM/DD/CCYY)

or Letter(s)

Surface

Code

Pointer

Qty.

Cavity

System

33. Missing Teeth Information

(Place an “X” on each missing tooth.)

34. Diagnosis Code List Qualifier

( ICD-10 = AB )

31a. Other

Fee(s)

34a. Diagnosis Code(s)

A _________________

C _________________

(Primary diagnosis in “A”)

B _________________

D _________________

32. Total Fee

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35. Remarks

AUTHORIZATIONS

ANCILLARY CLAIM/TREATMENT INFORMATION

36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all

38. Place of Treatment

(e.g. 11=office; 22=O/P Hospital)

39. Enclosures (Y or N)

charges for dental services and materials not paid by my dental benefit plan, unless prohibited by

(Use “Place of Service Codes for Professional Claims”)

law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all

or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure

40. Is Treatment for Orthodontics?

41. Date Appliance Placed (MM/DD/CCYY)

of my protected health information to carry out payment activities in connection with this claim.

No (Skip 41-42)

Yes (Complete 41-42)

X _____________________________________________________________________________

Patient/Guardian Signature

Date

42. Months of Treatment

43. Replacement of Prosthesis

44. Date of Prior Placement (MM/DD/CCYY)

Yes (Complete 44)

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly

to the below named dentist or dental entity.

45. Treatment Resulting from

X _____________________________________________________________________________

Occupational illness/injury

Auto accident

Other accident

Subscriber Signature

Date

46. Date of Accident (MM/DD/CCYY)

47. Auto Accident State

BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not

TREATING DENTIST AND TREATMENT LOCATION INFORMATION

submitting claim on behalf of the patient or insured/subscriber.)

53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require

multiple visits) or have been completed.

48. Name, Address, City, State, Zip Code

X________________________________________________________________________________

Signed (Treating Dentist)

Date

54. NPI

55. License Number

56. Address, City, State, Zip Code

56a. Provider

Specialty Code

49. NPI

50. License Number

51. SSN or TIN

52. Phone

52a. Additional

57. Phone

58. Additional

Number

Provider ID

Number

Provider ID

©2019 American Dental Association	To reorder call 800.947.4746
J430 (Same as ADA Dental Claim Form – J431, J432, J433, J434, J430D)	or go online at adacatalog.org

The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are posted on the ADA’s web site (https://www.ADA.org/en/publications/cdt/ada-dental-claim-form).

GENERAL INSTRUCTIONS

A.The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin.

B.Complete all items unless noted otherwise on the form or in the instructions posted on the ADA's web site (ADA.org).

C.Enter the full name of an individual or a full business name, address and zip code when a name and address field is required.

D.All dates must include the four-digit year.

E.If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a separate, fully completed claim form.

F.GENDER Codes (Items 7, 14 and 22) – M = Male; F = Female; U = Unknown

COORDINATION OF BENEFITS (COB)

When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the “Remarks” field (Item 35).

DIAGNOSIS CODING

The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions. Diagnosis codes are linked to procedures using the following fields:

Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a) Item 34 – Diagnosis Code List Qualifier (AB for ICD-10-CM)

Item 34a – Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter “A”)

PLACE OF TREATMENT

Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are:

11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nursing Facility; 32 = Nursing Facility

The full list is available online at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Website-POS-database.pdf

PROVIDER SPECIALTY

This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as “Dentist” may be used instead of any of the other codes.

Category / Description Code	Code
Dentist	122300000X
A dentist is a person qualified by a doctorate in dental surgery (D.D.S.)
or dental medicine (D.M.D.) licensed by the state to practice dentistry,
and practicing within the scope of that license.
General Practice	1223G0001X
Dental Specialty (see following list)	Various
Dental Public Health	1223D0001X
Endodontics	1223E0200X
Orthodontics	1223X0400X
Pediatric Dentistry	1223P0221X
Periodontics	1223P0300X
Prosthodontics	1223P0700X
Oral & Maxillofacial Pathology	1223P0106X
Oral & Maxillofacial Radiology	1223D0008X
Oral & Maxillofacial Surgery	1223S0112X

Provider taxonomy codes listed above are a subset of the full code set that is posted at: http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/

How to Edit Humana Dental Form Online for Free

Handful of things are simpler than filling in forms using this PDF editor. There isn't much you need to do to change the humana dental claim form file - simply abide by these steps in the following order:

Step 1: The very first step requires you to click the orange "Get Form Now" button.

Step 2: Now you can modify your humana dental claim form. Feel free to use our multifunctional toolbar to include, remove, and adjust the content of the form.

In order to complete the humana dental claim form PDF, enter the content for all of the parts:

Inside the segment Procedure Date MMDDCCYY, Area of Oral Cavity, Tooth System, Tooth Numbers or Letters, Tooth Surface, Procedure Code, a Diag Pointer, b Qty, Description, Fee, Missing Teeth Information Place, Diagnosis Code List Qualifier, ICD AB, a Diagnosis Codes, and Primary diagnosis in A type in the information the application requests you to do.

In the Name Address City State Zip Code, I hereby certify that the, multiple visits or have been, NPI, License Number, SSN or TIN, Phone Number American Dental, a Additional Provider ID, X Signed Treating Dentist, Date, NPI, Address City State Zip Code, License Number, a Provider Specialty Code, and Phone Number area, identify the vital particulars.

human dental claim Name Address City State Zip Code, I hereby certify that the, multiple visits or have been, NPI, License Number, SSN or TIN, Phone Number American Dental, a Additional Provider ID, X Signed Treating Dentist, Date, NPI, Address City State Zip Code, License Number, a Provider Specialty Code, and Phone Number fields to fill

Step 3: Hit the "Done" button. Next, you may export your PDF document - download it to your electronic device or send it through electronic mail.

Step 4: Create minimally several copies of the document to prevent all of the future challenges.

Humana Dental Form – Fill Out and Use This PDF

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