Fill in a Valid Humana Dental Template

The Humana Dental Claim Form is a vital document for individuals seeking reimbursement for dental services from their insurance provider. This form collects essential information about the policyholder, the patient, and the specific dental services rendered. Completing the Humana Dental form accurately is crucial for ensuring timely processing of claims, so be sure to fill it out carefully by clicking the button below.

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The Humana Dental Claim Form is an essential tool for policyholders and dental professionals alike, facilitating the processes of submitting claims and obtaining preauthorization for dental services. It includes clear sections such as header information, detailing the type of transaction, the policyholder's information, and the insurance coverage details. Users must input personal information such as names, addresses, and dates of birth to ensure accuracy and efficient processing. The form also outlines specific patient information and their relationship to the policyholder. A record of services provided section is crucial as it captures details of procedures performed, including dates, tooth numbers, diagnosis codes, and associated fees. Notably, it allows for multiple procedures to be reported, enhancing flexibility in claims submission. Other important aspects include spaces for treating dentist information and authorizations, ensuring consent for use and disclosure of protected health information. With its straightforward layout and comprehensive instructions, completing the Humana Dental Claim Form can be a straightforward process for all involved.

Humana Dental 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/

Click for Humana Dental File

File Breakdown

Fact Name	Description
Type of Transaction	The Humana Dental form allows various transaction types, including a Statement of Actual Services and requests for Predetermination or Preauthorization.
Policyholder Information	The form requires comprehensive information about the policyholder or subscriber, including name, address, and date of birth.
Patient Information	Information regarding the patient’s relationship to the policyholder must be included, along with the patient's gender and date of birth.
Record of Services	A detailed record of services provided is necessary, including procedure dates, tooth numbers, and associated fees.
Authorization and Signature	The form requires the signature of both the patient or guardian and the treating dentist to authorize payment and confirm the treatments received.

Guide to Using Humana Dental

Completing the Humana Dental form requires careful attention to a series of specific fields. Each section of the form captures essential information necessary for processing your dental claim. Follow these steps to ensure that you fill it out correctly.

Start with the Header Information section. Mark all applicable boxes for the type of transaction you are submitting.
Enter the Predetermination/Preauthorization Number if you have it.
In the Policyholder/Subscriber Information section, write the policyholder’s name, followed by their address, city, state, and zip code.
Complete the Dental Benefit Plan Information section by filling in the company or plan name and their address, city, state, and zip code.
Add the policyholder’s Date of Birth in the format MM/DD/CCYY and their gender.
List the Policyholder/Subscriber ID assigned by the plan.
If applicable, indicate whether the coverage is Dental or Medical.
If there is other coverage, complete the relevant fields (5-11) regarding the other plan.
Provide the Patient Information by including the patient's relationship to the policyholder, their date of birth, and gender.
Input the patient's name, address, city, state, and zip code.
Outline the patient's relationship to the person named in #5.
Fill out any applicable information regarding other insurance companies or dental benefit plans.
In the Record of Services Provided section, document the procedure date, area, tooth number(s), description of services, and corresponding fees.
If there are missing teeth, mark “X” for each one.
Include any Diagnosis Codes as required for the procedures.
In the Authourizations section, provide your signature and date to confirm treatment acceptance and payment responsibilities.
If applicable, complete the sections regarding orthodontics and prosthesis replacement.
Complete the Billing Dentist or Dental Entity information if the dentist is submitting the claim. Include their name, address, and licensing information.
Sign the form where indicated and enter the date.

After filling out the form, double-check for any missing information to avoid processing delays. Folding the completed form correctly allows it to fit into a standard envelope for mailing. Be sure to keep a copy of the completed form for your records before submission.

Get Answers on Humana Dental

What is the Humana Dental Claim Form and why do I need it?

The Humana Dental Claim Form is an official document used to request reimbursement for dental services covered under your Humana dental plan. When you receive dental treatment, this form allows you to submit the details of the services provided to your insurance carrier. It ensures that you or your provider can receive payment for the services rendered. By correctly filling out this form, you help facilitate a smooth claims process, which can ultimately save you time and money.

How do I complete the Humana Dental Claim Form?

To fill out the Humana Dental Claim Form accurately, follow these steps:

Start with the header information, marking the type of transaction that applies to your situation, like a statement of actual services or a request for predetermination.
Provide details about the policyholder or subscriber, including their name, address, and date of birth.
Next, fill in the dental benefit plan information, including the plan name and subscriber ID.
Include patient information, indicating the relationship to the policyholder and the patient's details, such as date of birth and gender.
Finally, document the record of services provided, including procedure dates, diagnosis codes, and associated fees.

Ensure to double-check all entries for accuracy. Missing or incorrect information can delay your claim processing.

What should I do if I have other dental insurance coverage?

If you have secondary dental insurance, you will need to coordinate benefits between your two insurance providers. On the Humana Dental Claim Form, mark the "Other Coverage" section and complete the required fields with your secondary insurance information. Be sure to include the Explanation of Benefits (EOB) from the primary insurance payer when submitting your claim. This documentation helps avoid delays in processing your claim and ensures that both insurance companies fulfill their obligations effectively.

How can I track the status of my claim after submission?

Your policyholder ID.
The date of service for which you filed the claim.

You may also receive notifications via mail or email regarding the status of your claim. If a significant amount of time passes without updates, don’t hesitate to reach out directly to Humana’s support team for assistance. Maintaining communication ensures you stay informed about any potential issues or required additional documentation.

Common mistakes

Completing the Humana Dental form can seem daunting, and mistakes can lead to delays or denial of claims. One common error occurs in the header information section. Often, individuals forget to mark all applicable boxes for transaction types, such as whether they are submitting a Statement of Actual Services or Requesting Predetermination. This oversight can result in the claim being misdirected or processed incorrectly. Ensuring every relevant box is checked provides clarity and streamlines the process.

Another frequent mistake involves the policyholder and subscriber information. The form requires complete and accurate details, including the policyholder's full name, address, and Subscriber ID. Individuals sometimes omit middle initials or fail to provide the correct suffix, leading to discrepancies. Always double-check that the information matches what the insurance plan has on file. This ensures that the form is associated with the correct account and prevents potential issues in payment processing.

Attention often shifts to patient details, where a common misstep can be found in filling out the patient information fields. Specifically, individuals may mistakenly use outdated or incorrect relationship definitions, such as inadvertently marking a child as a spouse. Such errors can complicate matters, as insurance plans may reference these definitions to establish eligibility for benefits. It is vital to confirm the relationship to ensure compliance with insurance policies.

Lastly, errors sometimes arise in the record of services provided section. Many claimants neglect to fill out diagnostic codes or procedure details completely. Failing to provide accurate diagnosis codes associated with each procedure can affect claim adjudication and could result in denied claims or reduced benefits. Filling this section carefully, using the guidelines provided for diagnosis coding, assures that all relevant information is available for the review process.

Documents used along the form

The Humana Dental form is a critical document used to process dental claims for services rendered. However, it often accompanies several other forms and documents that help ensure accurate information is shared and benefits are appropriately administered. The following list describes some common documents that may be used alongside the Humana Dental form.

Explanation of Benefits (EOB): This document is issued by an insurance provider after a claim is processed. It details what costs were covered, how much was paid, and what remaining balances may be owed by the subscriber.
Patient Registration Form: This form collects essential information from the patient, such as contact details, insurance information, and medical history. It supports accurate billing and care provision.
Authorization for Release of Information: This form allows a dental office to share a patient’s health information with third parties, such as insurance companies. It is necessary for processing claims efficiently and legally.
Financial Agreement: This agreement outlines the financial responsibilities between the patient and the dental provider. It details payment plans, additional costs, and payment expectations for treatments.
Treatment Plan: This document provides a comprehensive outline of proposed dental procedures necessary for the patient's health. It often includes the expected costs and may be required for pre-authorization from the insurance provider.
Coordination of Benefits (COB) Form: When patients have multiple insurance plans, this form helps clarify the order in which claims will be paid. It is crucial for ensuring all benefits are utilized effectively.
Claim Appeal Form: If a dental claim is denied, this form is used to formally contest the decision. Providing additional information or corrections may be necessary to resolve any issues related to the claim.
Diagnostic Radiographs (X-rays): X-rays are often included with the claim to provide visual support for the procedures performed. They help justify the need for specific treatments and support the claims process.
Consent for Treatment: This document confirms the patient's understanding and agreement to the proposed dental procedures. It is essential for legal and ethical practice, ensuring informed consent is obtained.

Using these documents in conjunction with the Humana Dental form can facilitate a smoother process for claims submission and processing. Each serves a distinct yet collaborative role in managing a patient’s dental insurance and healthcare communication.

Similar forms

ADA Dental Claim Form: Like the Humana Dental form, this document is used to submit claims for dental services. It asks for similar information, including patient data, procedure details, and billing dentist information.
Insurance Claim Form: Similar to the dental form, this document is used for healthcare claims. It generally requires details about the patient, services rendered, and relevant insurance details, ensuring proper reimbursement from insurance providers.
Medical Benefit Claim Form: This form is used for medical insurance claims. It shares the need for patient identification, policy numbers, and details about services provided, paralleling the requirements seen in dental claims.
Health Savings Account (HSA) Reimbursement Form: This document requests reimbursement for qualified medical expenses from an HSA. It requires similar identification information and documentation of expenses, resembling the claim submission process.
Coordination of Benefits (COB) Form: Used when a patient has multiple insurance policies, this form details coverage across plans. It requires comprehensive information about the patient and their insurance, akin to what is collected on the Humana Dental form.
Medicare Claim Form: Designed for Medicare beneficiaries, this form requests reimbursement for medical services. It asks for patient identification, service information, and provider details similar to both dental and general medical claim forms.

Dos and Don'ts

When filling out the Humana Dental form, keeping certain guidelines in mind can help ensure a smooth submission process. Below is a list of things to do and avoid.

Do: Complete all items on the form, unless otherwise specified.
Do: Ensure the patient's name and address are fully written out in required fields.
Do: Use a four-digit year for all dates to avoid confusion.
Do: Submit a separate claim form for additional procedures if there are not enough lines available.
Do: Provide the Place of Service Code to indicate where the treatment was administered.

Don't: Leave any required fields blank, as this can delay processing.
Don't: Use abbreviations for names or addresses; full details must be included.
Don't: Submit the form without the primary payer's Explanation of Benefits if it's for a secondary claim.
Don't: Forget to include relevant diagnosis codes when filing for procedures that may require them.

Misconceptions

Misconception 1: The Humana Dental form only handles claims for dental services.

Some individuals believe that the Humana Dental form can only be used for dental services. However, it can also accommodate requests for predetermination and preauthorization for dental treatments, ensuring that patients can understand their coverage options before undergoing procedures.

Misconception 2: Completing the form is not necessary if you have electronic benefits verification.

Many assume that electronic benefits verification alone eliminates the need to complete the Humana Dental form. In reality, the form must still be submitted to provide detailed information about the services rendered, even if benefits have been confirmed electronically.

Misconception 3: The patient’s signature is optional on the claim form.

There is a belief that obtaining the patient's signature on the Humana Dental form is optional. In truth, the patient's or guardian's signature is crucial, as it authorizes the payment to the dental provider and confirms that the patient agrees to the terms outlined.

Misconception 4: Diagnosis codes are not necessary for all dental procedures.

Some people think that diagnosis coding is only needed for specific procedures. However, accurate diagnosis codes must be reported for each service to facilitate proper claim adjudication and link related procedures to the patient's health history.

Misconception 5: Missing teeth information is not important on the claim form.

Individuals may overlook the importance of documenting missing teeth. Filling out this information is essential for comprehensive treatment planning and enables the insurance provider to assess the patient's condition accurately.

Misconception 6: If there is other insurance coverage, you do not need to complete the Humana Dental form.

It is a common misunderstanding that other insurance coverage makes it unnecessary to fill out the form. In fact, it is crucial to complete the Humana Dental form while also providing information about other insurance to ensure proper coordination of benefits.

Misconception 7: The form is only valid if completed in pen.

Some believe that the Humana Dental form must be filled out using pen. It can be completed digitally as well, allowing for clearer entries and reducing the likelihood of errors due to handwriting.

Key takeaways

When filling out and utilizing the Humana Dental form, several important components should be carefully considered to ensure a smooth processing experience.

Transaction Type: Indicate the type of transaction clearly at the beginning. Options include Statement of Actual Services and Request for Predetermination.
Accurate Information: Provide complete details for the policyholder, including full name, address, and date of birth. Incomplete data can lead to delays or denials.
Relationship to Patient: Clearly identify the relationship between the patient and the policyholder. This information is vital for accurate claim processing.
Diagnosis Codes: Include up to four diagnosis codes relevant to the treatment. Accurate coding helps in determining the legitimacy of the claim.
Provider Information: The dentist’s or dental entity’s information must be complete. This includes their address, license number, and whether they are the treating provider.
Coordination of Benefits: If applicable, attach the primary payer’s Explanation of Benefits (EOB) when submitting the claim to a secondary payer. This ensures proper payment allocation.
Review Before Submission: Take a moment to review the form for errors or omissions before submitting. Ensuring accuracy can reduce the chances of claim delays or denials.

Following these guidelines will enhance the effectiveness of the claims process, facilitating timely responses and reducing unnecessary stress.