Follow the steps to successfully complete your Claim Form

1. Press the ‘Get Form’ button to access the form and open it in the provided editor. This will enable you to fill out the necessary information online.
2. Begin with the type of transaction. Indicate whether you are completing a statement of actual services or a predetermination request by checking the appropriate box.
3. In the Subscriber Information section, input the subscriber's name (last, first, middle initial), address, city, state, and ZIP code. Make sure all information is accurate.
4. If applicable, provide details on any other dental or medical coverage. Indicate the name and address of the other insurance company, and specify the subscriber ID and payment amount if you have primary insurance.
5. Fill in the Patient Information section by providing the patient's name and date of birth, along with their relationship to the subscriber. Clearly denote whether they are a self, spouse, child, or other.
6. Complete the Dental Services section by entering the date of service, treatment information (tooth number, description, and procedure code), and the total fee charged. Be sure to use current ADA CDT procedure codes.
7. In the Remarks section, provide any additional information necessary to process the claim, including non-standard COB or miscellaneous codes.
8. Fill out the Billing Dentist section by entering the dentist's name, address, license number, NPI, and TIN, ensuring that the information matches Renaissance’s records.
9. Review your entries for accuracy. Any mistakes can delay processing, so double-check all fields, especially those requiring numerical input or sensitive information.
10. Once you have filled out all relevant fields and sections, you can save changes, download, print, or share the completed form.

Ready to submit your claim? Fill out your Claim Form online now.