Dental Authorization / X-Ray Submission Form


Dental X-Rays can be submitted to one of the providerConnect™ Participating Carriers/Adjudicators/Third Party Payors. You will find your unique Provider Number on your statement from the Participating Carriers/Adjudicators/Third Party Payors outlined in Schedule A within your Provider of Service Agreement – Health and Professional Services.
 
 Many procedures do not require x-rays or digital photos for approval. We recommend you first submit your predetermination to us via your dental software. If you are unable to do so, providerConnect is an alternative to sending us x-rays or photos manually through the mail.

 * indicates a mandatory field

Provider Information
If you sign into Secure Services, the provider information will be pre-populated, saving you time.
  
  
  
  
  
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Patient Information
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[yyyy mm dd]
  
  
  
  
  
Patient History/Chart Information
 
Patient History - Bridges (A= Abutment P= Pontic I= Implant)
Patient History - Bridges (A= Abutment P= Pontic I= Implant)
Patient History - Bridges1
Patient History - Bridges2
Patient History - Bridges3
Patient History - Bridges4
Patient History - Missing Teeth and Endodontic Treatments (E=Endo M=Missing)
Patient History - Missing Teeth and Endodontic Treatments (E=Endo M=Missing)
  Required information for a bridge or implant. Processing times will be delayed if not completed.
Patient History - Missing Teeth and Endodontic Treatments (E=Endo M=Missing)
Patient History
Patient History - 1
Patient History - 2
Patient History - 3
Patient History - 4
Authorization/Predetermination Information
Dental PDT info table
Dental PDT info
Int’l Tooth Code Tooth Surfaces (e.g. MOD) Procedure Code* Provider's Fee* Laboratory Charges
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row
surfaceC surfaceT surfaceL surfaceB surfaceR
Dental PDT data entry
Remove Row

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Comments 
Comments  (limit 1000 characters)  0 *
File Attachments (Expertise statements, x-rays and/or photos may be attached.)
 * At minimum one upload is required.
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This is an approximation only.
Final laboratory charges will be included on claim form when treatment is completed.

By submitting this form, I acknowledge that the Plan Member has given written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor necessary for claims adjudication, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer this benefit claim and/or to confirm the accuracy of this information.

I agree that the information provided is complete and accurate, to the best of my knowledge.