You'll need some information from the dentist (these will help fill in boxes 24-35):
- A treatment plan, or a list of the ADA codes and their fees
- A narrative of medical necessity
- The provider's information (Tax ID, NPI, and address)
Detailed form walkthrough_____________________________________________________________________________
You need to fill in box 1--typically, you will be submitting a statement of actual services.
Other coverage: If the patient has a secondary dental insurance policy with another carrier, fill in boxes 4-11.
Policyholder/Subscriber information: Enter the details for the primary subscriber for the policy in boxes 12-17.
Patient information: Enter the details for the patient in boxes 18-23, even if the patient is also the subscriber.
Record of services provided: For boxes 24-35, you will need to have your dentist assist with submitting the correct ADA procedure codes and fee amounts, missing teeth numbers, and remarks.
Authorizations: Box 36 indicates that you are responsible for paying for the services provided even if the insurance plan does not cover all or a portion of the treatment. This box must be signed. Box 37 you will only sign if you want Beam Benefits to send payment to your dentist instead of to you.
Ancillary claim/Treatment information: This section is important if you are submitting orthodontics or prosthetics claims. For orthodontics, fill in boxes 40-42. For prosthetics, fill in boxes 43 and 44.
Billing dentist or Dental entity: Leave this blank if you are a member submitting the claim on your own behalf.
Treating dentist and Treatment location information: Have your dentist fill out this portion. Once everything is filled out, you can email us the form at email@example.com.
If your claim is for basic or major services, contact Beam Benefits with the ADA procedure codes so that we can advise you of what documentation to include with the claim for it to be processed. You can reach us by email at firstname.lastname@example.org