Get Delta Dental Of Illinois Referral Claim Form

Filling out the Delta Dental Of Illinois Referral Claim Form online is a straightforward process that allows users to efficiently submit their claims. This guide provides step-by-step instructions to help individuals complete the form accurately and confidently.

Follow the steps to successfully complete the Delta Dental Of Illinois Referral Claim Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reviewing the header information. Fill out the Carrier Name and Address, ensuring that you accurately complete the 'Type of Transaction' section by checking the applicable boxes for either 'Statement of Actual Services' or 'Request for Predetermination/Preauthorization'.
3. Next, provide the primary payer information. Include 'Delta Dental of Illinois' and their address. Proceed to fill out the patient's name, address, and other relevant coverage details under 'Other Coverage'. If the patient has other dental or medical coverage, select 'Yes' and complete the necessary fields.
4. Proceed to fill out the primary subscriber information. Input the subscriber's name, date of birth, and gender. Also, include the subscriber identifier, plan/group number, and employer name.
5. In the patient information section, indicate the patient's relationship to the primary subscriber, selecting the applicable box. Then complete the patient's name, date of birth, gender, and any patient ID/account number provided by the dentist.
6. Complete the record of services provided by entering the procedure date, area of the oral cavity, tooth system, tooth number(s), surface, procedure code, description, and fee. If there are any missing teeth, mark them in the designated section.
7. In the 'Authorizations' section, confirm that the patient has been informed of the treatment plan and fees. Obtain the patient or guardian's signature and the date.
8. Finally, for billing information, provide the treating dentist or dental entity's details, including name, address, and phone number. The treating dentist must also sign and date the statement certifying the procedures.
9. Once all fields are completed, review the form for accuracy. You may save changes, download, print, or share the completed form as needed.

Start filling out your Delta Dental Of Illinois Referral Claim Form online now to ensure timely processing of your claims.