How to file a dental claim

Delta Dental dentists will handle all claims and paperwork for you. However, if you visit a non-Delta Dental dentist, you may need to file the claim yourself.

If you do need to file a claim form:

  1. Download the claim form for your Delta Dental plan:
  1. Complete the patient and subscriber information on the claim form.
  2. Provide a copy of the dentist's Statement of Treatment or a detailed receipt that includes:
    • Name, address and complete phone number of dentist
    • Date each service was performed
    • Description, procedure code and fee of each service performed
    • List of affected teeth
    • Total cost of services performed
    • Dentist's National Provider Identifier (NPI)
    • Dentist’s Tax Identification Number (TIN)
    • State license number
    • Specialty code

    Important note: If the Statement of Treatment or similar document you receive from your dentist is missing any of the information listed in Step 3, please enter it on the claim form. A dental office staff member can provide you with the dentist and treatment information.

  3. Make a copy of the completed claim form and the dentist’s Statement of Treatment or detailed receipt for your records.
  4. Mail the original copies of the completed claim form and the dentist’s Statement of Treatment or detailed receipt to the address printed on the claim form. To display the address on the Delta Dental PPO, DPO and Delta Dental Premier form, choose the Delta Dental member company for your plan from the interactive “Select your Plan” drop-down list at the top of the form.

We usually process claims within two weeks unless additional information is required from you or the dentist.

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