Claim for Dental Benefits Aetna Life Insurance Company PO Box 14094 Lexington, KY 40512-4094 1-877-238-6200 MAIL TO: NEW JERSEY STATE DENTAL EXPENSE PLAN CLAIM SERVICES PROVIDED BY AETNA LIFE INSURANCE COMPANY 1. Patient Name 2. Relationship To Subscriber TO BE COMPLETED BY SUBSCRIBER Self Spouse 3. Sex Child Other M F 4. Patient Birthdate MM DD 5. Payor Code YYYY 60054 6. Subscriber Name Subscriber Birthdate First Middle MM Last 7. Subscriber Social Security No. DD YYYY 9. Subscriber Mailing Address Zip 11. Group Number Retiree Leave of Absence DD YYYY COBRA Yes 13. Name and Address of Employer in Item 12. Soc. Sec. No. 14. Is Patient Covered by Another Dental Plan? No Yes If yes, please give: Dental Plan Name Name and Address of Carrier 15. If patient is a Dependent Child are the Legal Parents divorced or separated from each Yes other? No 15a. I have reviewed the following treatment plan. I authorize release of any information relating to this claim. _________________________________________________ _________________ Signed (Patient, or Parent if minor) 16. Dentist Name First Active MM Employer Name: 12. Are Other Family Members Employed? No Member Name 812310 Spouse/Partner Birthdate Single Divorced Married Separated Domestic Partnership 10. Employment Status: City, State 8. Status 15b. I hereby certify that the above information is correct. _________________________________________________ Middle 24. Is treatment result of occupational illness or injury? 25. Is treatment result of auto accident? Last 17. Mailing Address _________________ Subscriber Signature Date No Yes Date If yes, enter brief description and dates 26. Other accident? City, State Zip 18. Dentist Soc. Sec. or T.I.N. TO BE COMPLETED BY DENTIST 21. First Visit Date Current series 19. Dentist License No. 22. Place of Treatment Office Hosp ECF Dentist - Check One Pretreatment estimate Statement of actual services IDENTIFY MISSING TEETH WITH “X” Tooth No. Or Ltr 27. Are any services covered by another plan? 28. If prosthesis, crown or inlay, is this initial placement? 20. Dentist Phone No. No Yes How Many? 30. Is treatment for orthodontics? MM DD YYYY 32. REMARKS FOR UNUSUAL SERVICES TOTAL FEE CHARGED TO BE COMPLETED BY DENTIST I HEREBY CERTIFY THAT THE PROCEDURES AS INDICATED BY DATE HAVE BEEN COMPLETED AND THAT THE FEES SUBMITTED ARE THE ACTUAL FEES I HAVE CHARGED THIS PATIENT AND INTEND TO ACCEPT FOR THESE PROCEDURES. DENTIST’S SIGNATURE: DATE: _________ DIRECTION TO PAY BENEFITS TO DENTIST DATE: ______________ IMPORTANT - to insure the proper processing of this claim, please check the accuracy of the following: Subscriber Questions - 1 through 15b Dentist Questions - 16 through 31, dates of services, & procedure numbers If initial prosthesis, list date(s) of extraction(s) for teeth being replaced. GC-14848 (9-04) Administrative Use Only Patient’s Eligible Date Mo._____________Day________Yr..___________ Patient’s Effective Date Mo._____________Day________Yr..___________ Patient’s Termination Date I HEREBY DIRECT BENEFITS PAYABLE TO THE ATTENDING DENTIST. SUBSCRIBER SIGNATURE: 29. Date of prior placement If services Date appliances placed Mos.Treatment already remaining commenced enter ADMINISTRATIVE 31. EXAMINATION AND TREATMENT PLAN - LIST IN ORDER FROM TOOTH NO. 1 THROUGH TOOTH NO. 32 USE ONLY USE CHARTING SYSTEM SHOWN Surface DESCRIPTION OF SERVICES Date Service Procedure FEE (Including X-Rays, Prophylaxis, Materials Used, etc.) Performed Number other 23. Radiographs or Models Enclosed (If no, reason for replacement) Mo._____________Day________Yr..___________ Verified by____________________________________________ Date Verified Mo._______________Day___________Yr. _____________ NEW JERSEY STATE DENTAL EXPENSE PLAN CLAIM INSTRUCTIONS Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant. NOTE: INCOMPLETE CLAIM FORMS WILL BE RETURNED TO YOU FOR MISSING INFORMATION. THIS WILL DELAY PAYMENT OF YOUR CLAIM. TO THE SUBSCRIBER 1. Complete items one (1) through fifteen (15) in full. Be certain to sign the authorization to release information block and the certification block (15a and 15b). 2. If you wish to have your benefits for this claim paid directly to your dentist, sign the “Direction to pay benefits to dentist” block located below the dentist certification. If total charges for the planned course of treatment are expected to exceed the minimum Predetermination dollar amount stated in your dental plan booklet, it is suggested that you file for Predetermination of Benefits. Aetna will notify your dentist of the benefits payable. NOTE: YOUR DENTAL COVERAGE IS SUBJECT TO SPECIFIC LIMITATIONS AND EXCLUSIONS. PLEASE REFER TO YOUR DENTAL BOOKLET FOR A DESCRIPTION OF COVERED EXPENSES, DEDUCTIBLES, COINSURANCE INFORMATION, AND LIMITATIONS AND EXCLUSIONS. TO THE DENTIST 1. COMPLETED SERVICES ⎯ Check the box noted “STATEMENT OF ACTUAL SERVICES” and complete items 16 through 31. When entering the treatment plan on the form, please indicate a separate fee for each individual service rendered. When the work is finished, sign the form and mail to the address shown in the upper right hand corner of the reverse side of this form. 2. PREDETERMINATION OF BENEFITS ⎯ If total charges for this claim are to exceed the minimum Predetermination dollar amount indicated in the subscriber’s Dental Plan Booklet (and treatment is not emergency in nature), Predetermination of Benefits is suggested. Check the box marked “PRETREATMENT ESTIMATE”, and complete items 16 through 31. Please be sure to answer questions 28 and 29 if the claim includes metal restorations, crowns, bridgework or dentures.* The completed form should be sent to the address shown in the upper right hand corner of the reverse side of this form. Aetna will notify you of the benefits payable for this course of treatment. When treatment has been completed, fill in the date each service was provided, sign the form and return to the address shown in the upper right hand corner of the reverse side of this form for payment. NOTE: PREDETERMINATION OF BENEFITS IS INTENDED TO AVOID MISUNDERSTANDINGS BETWEEN THE SUBSCRIBER, DENTIST AND INSURANCE COMPANY CONCERNING BENEFITS PAYABLE. YOU AND YOUR PATIENT ARE, OF COURSE, FREE TO PURSUE ANY TREATMENT PLAN YOU THINK BEST. 3. If the subscriber indicates that benefits should be paid directly to the dentist, then these benefits will be sent directly to you with an information copy of the transaction to the subscriber. *X-rays taken for metal restorations and crowns should be submitted with treatment plan. They may also be requested for other services. X-rays will be reviewed and returned promptly.
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