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Fill Out Your Guardian Dental Claim Form

The Guardian Dental Claim Form is a standardized document used to submit claims for dental services to insurance companies or dental benefit plans. It captures essential information about the patient, policyholder, and the services provided, ensuring that claims are processed efficiently. For those needing to submit a dental claim, filling out this form accurately is crucial; get started by clicking the button below.

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Article Structure

The Guardian Dental Claim form plays a crucial role in streamlined processing of dental insurance claims. This comprehensive document captures essential information about the policyholder and patient, such as names, addresses, and insurance details. It includes a section for recording services provided, detailing the procedure dates, types of treatment, and associated fees. The form also facilitates the coordination of benefits, allowing users to report procedures and diagnosis codes that are necessary for successful claim adjudication. Moreover, patients can authorize direct payments to their dentist, ensuring efficient financial transactions. Clear instructions guide users through each section, maintaining organization and thoroughness to minimize errors. Understanding how to fill out this form accurately can significantly impact the speed and success of claims processing.

Guardian Dental Claim Example

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Dental Claim Form

HEADER INFORMATION

Guardian

1. Type of Transaction (Mark all applicable boxes)

Individual Dental Claims

Statement of Actual Services

Request for Predetermination/Preauthorization

PO Box 254888

EPSDT / Title XIX

Sacramento, CA 95865-9005

POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)

2. Predetermination/Preauthorization Number

12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

Insurance Company/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 (SSN or ID#)

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 (SSN or ID#)

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-9 = B; ICD-10 = AB )

31a. Other

Fee(s)

34a. Diagnosis Code(s)

A _________________

C _________________

(Primary diagnosis in “A”)

B _________________

D _________________

32. Total Fee

$0.00

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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

©2012 American Dental Association	To reorder call 800.947.4746
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)	or go online at adacatalog.org

The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).

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 CDT manual’s instructions.

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.

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). There are additional detailed completion instructions in the CDT manual.

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 (B for ICD-9-CM; 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 “www.cms.gov/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 “www.wpc-edi.com/codes/taxonomy”

Get Guardian Dental Claim PDF Form

Form Characteristics

Fact Name	Fact Description
Transaction Types	The Guardian Dental Claim Form allows individuals to mark the applicable transaction types, such as Individual Dental Claims and Request for Predetermination/Preauthorization.
Policyholder Identification	Information about the policyholder, including name, address, and contact details, is crucial for processing the claim effectively.
Patient Relationship	The form requires you to indicate the patient's relationship to the policyholder, which helps clarify who is receiving the treatment.
Service Records	A detailed record of services provided, including procedure dates and fees, must be documented accurately on the form.
Diagnosis Codes	The form supports reporting up to four diagnosis codes to enhance the claim's accuracy and expedite processing.
Coordination of Benefits	If there’s a secondary payer, attach the primary payer’s Explanation of Benefits (EOB) to ensure clear communication between insurance companies.
Place of Treatment Codes	Claims must include a 2-digit Place of Service Code, helping insurers understand where the dental treatment occurred.
Provider Specialty Code	The form requires detailing the dental provider's specialty, which aids in proper claims evaluation based on the dentist's expertise.
Authorized Signature	Both the patient and the subscriber must sign at specified areas, confirming their consent and understanding of the treatment plan and associated fees.
For California Residents	For claims in California, be aware that regulations under the California Insurance Code may apply when completing the form.

Guidelines on Utilizing Guardian Dental Claim

Filling out the Guardian Dental Claim form is an essential process for obtaining reimbursement for dental services. Proper completion of the form ensures that your claim is processed efficiently and accurately. Here’s a step-by-step guide for making this process straightforward.

Type of Transaction: In the header, mark all applicable boxes, selecting options such as "Individual Dental Claims" or "Statement of Actual Services."
Policyholder/Subscriber Information: Provide the Policyholder/Subscriber name, including last, first, middle initial, and suffix. Include their address, city, state, and zip code.
Insurance Company Details: Enter the name and address of the insurance company or dental benefit plan.
Date of Birth: Fill in the policyholder’s date of birth in MM/DD/YYYY format.
Gender: Select the appropriate gender option (M, F, or other).
Policyholder/Subscriber ID: Input the Social Security Number or ID number as required.
Plan/Group Number: Enter the plan or group number associated with the policyholder.
Employer Name: Fill in the name of the employer related to the insurance plan.
Patient Information: Enter the patient’s details, including relationship to the policyholder, name, address, date of birth, and gender.
Relationship to Policyholder: Specify the relationship (self, spouse, dependent, other).
Procedure Details: List the services provided, including the procedure date, tooth numbers, and fee for each service.
Diagnosis Codes: Include up to four diagnosis codes relevant to the procedures performed.
Total Fee: Specify the total fee amount for all services rendered.
Authorizations: Sign and date the form, acknowledging the treatment plan and giving authorization for payment to be directed to the dentist.
Treating Dentist Information: Provide the name and address of the treating dentist, including their NPI and license number.
Enclosures: Indicate if there are any enclosures accompanying the claim.

Make sure all sections are thoroughly completed and double-check the accuracy of the information provided. A correctly filled form will help expedite your claim processing and ensure that you receive the benefits you are entitled to without unnecessary delays. Take your time and, if needed, refer back to any available resources for help with specific sections of the form.

What You Should Know About This Form

What is the Guardian Dental Claim form used for?

The Guardian Dental Claim form is used to submit claims for dental services to Guardian Life Insurance Company or associated dental benefit plans. This form helps ensure that the insurance provider processes and reimburses the costs of received dental care efficiently.

How do I fill out the Guardian Dental Claim form?

The form requires specific information about the policyholder, the patient, the provider, and services rendered. It's essential to complete all required fields accurately, including names, addresses, dates of service, and procedure codes. You may also need to provide diagnosis codes that correspond with each dental procedure.

What should I do if I need to report multiple procedures?

If the number of procedures exceeds the lines available on the form, you should complete a separate claim form for the additional procedures. Ensure that each form is fully completed to avoid processing delays.

Can I submit my claim form if I have secondary insurance?

Yes, you can submit the Guardian Dental Claim form if you have secondary insurance. Make sure to complete the form entirely and attach the primary payer's Explanation of Benefits (EOB) which details the amount they paid. This will help the secondary insurer process your claim accurately.

What should I include in the 'Diagnosis Code' section?

You need to enter up to four diagnosis codes for your dental procedures. These codes help the insurance company understand the medical necessity of the treatments provided. Make sure to link the appropriate diagnosis codes to their respective procedures using the provided pointers on the form.

What information do I need to provide about the treating dentist?

You'll need to include the name, address, and other relevant identifiers of the treating dentist or dental entity. If the dentist is submitting the form on your behalf, ensure they sign and date the authorization to direct payment for services rendered.

Is there a specific way to submit the Guardian Dental Claim form?

Yes, the form should be folded properly to ensure the insurance company's address is visible in a standard window envelope. Follow the "tick-marks" on the margin for proper folding, and send it to the address indicated at the top of the form.

What if I have questions about completing the form?

If you have questions about completing the Guardian Dental Claim form, refer to the instructions provided in the CDT manual. You can also visit the ADA’s website for further guidance, or reach out to your dentist's office for assistance.

How can I track the status of my dental claim?

To track the status of your dental claim, you will typically need to contact Guardian Life Insurance Company directly. Have your claim number and any relevant information ready to facilitate the inquiry.

Common mistakes

Filling out the Guardian Dental Claim form accurately is essential for ensuring timely processing of claims. However, many individuals make common errors that can lead to delays or rejections. Here are eight mistakes to avoid when completing this form.

The first mistake often involves incomplete information. It's crucial to fill out all fields unless specifically marked as optional. Failure to provide the full name, address, or identification numbers can trigger further inquiries from the insurance provider, unnecessarily prolonging claim processing.

Another frequent error occurs when individuals neglect to specify the type of transaction correctly. Marking all applicable boxes under "Type of Transaction" is essential, as this informs the insurance company about the claim's nature, whether it's for dental services, preauthorization, or actual services rendered.

Dates are another area where mistakes commonly happen. Claims submitted with incomplete dates or incorrect formats may be delayed. Remember that all dates must include the four-digit year, fulfilling the form's requirements accurately.

Many also overlook the requirement for diagnosis codes. Proper diagnosis coding is vital as it directly affects the claim's adjudication. Ensure that diagnosis codes are linked correctly to specific procedures and that you are using the appropriate code qualifiers.

Failing to submit supporting documentation can cause additional complications. If you are submitting a claim to a secondary payer, attach the primary payer’s Explanation of Benefits (EOB). This documentation is necessary for verifying the amount covered by the primary insurer.

Additionally, many claimants forget to complete the “Remarks” section. This optional area can be effective for indicating any necessary details, such as the primary carrier's paid amount or other relevant information that may help in processing the claim.

Accuracy in patient identification is also critical. Ensure the relationship to the policyholder is appropriately marked and that the policyholder's identification number is stated correctly. Mistakes in this area may lead to identification disputes, hindering claim approval.

Lastly, not checking for completeness before submitting the form is a common downfall. It is advisable to review the entire form for errors or omissions. Taking a moment to verify that all sections are accurately filled out can make the difference between a smoothly processed claim and a frustrating delay.

Documents used along the form

When submitting a dental claim using the Guardian Dental Claim form, it’s often necessary to include additional documentation to ensure a streamlined process. These documents provide pertinent information regarding the treatment and payment, helping insurance companies process claims more effectively. Below is a list of documents commonly used in conjunction with the Guardian Dental Claim form.

Explanation of Benefits (EOB): This document outlines the insurance company's payment decisions, detailing which services were covered, the amount paid, and any patient responsibility like co-pays or deductibles.
Preauthorization Request: If the dental service required preapproval, this request form specifies the procedures needing authorization before treatment can commence, ensuring eligibility for benefits.
Patient Consent Form: This form confirms that the patient understands and agrees to the treatment plan. It is crucial for maintaining transparency between the dentist and the patient.
Billing Statement from Dentist: This statement provides a summary of services rendered, including the costs associated with each service. It mirrors the details on the claim form for consistency.
Referral Form: If a specialist was involved, this document outlines the referral from the primary dentist, clarifying the necessity of specialized services within the broader treatment plan.
Claim Submission Checklist: A simple checklist helps ensure all necessary documents are submitted with the claim, preventing potential delays due to incomplete information.
Insurance Card Copy: Providing a copy of the patient's insurance card validates the policyholder’s coverage and allows for quicker verification during the claims process.
Procedure Notes: These notes may include detailed descriptions of procedures performed, which can help clarify the medical necessity of the treatment when examined by the insurance company.
Dental X-rays: Including X-rays can substantiate the claimed dental procedures by providing visual evidence of the condition or treatment necessity.
Previous Treatment Records: If applicable, these records help demonstrate the continuity of care and explain past treatment decisions, which may relate to the current claim.

Incorporating these documents when submitting a dental claim can facilitate smoother processing and reduce the likelihood of delays or disputes. It is advisable to maintain meticulous records and ensure that all required information is accurately represented to optimize the claims experience.

Similar forms

The Guardian Dental Claim form shares similarities with several other documents that are commonly used in dental and medical claims processing. Below is a list of ten documents that exhibit comparable features:

ADA Dental Claim Form: This form serves a similar purpose in that it captures essential patient and procedure information for dental claims submissions, ensuring consistency in the claims process.
CMS-1500 Form: Used for medical claims, this form is structured to gather comprehensive patient, diagnosis, and billing details pertinent to insurance providers.
UB-04 Form: This standardized claim form for hospitals captures patient information and charges similar to what the Guardian form does for dental services.
Patient Registration Form: Both documents require fundamental patient information, such as name, date of birth, and insurance details, facilitating the claims process.
Coordination of Benefits (COB) Form: Like the Guardian form, this document is designed to gather details when multiple insurance coverage is involved, helping to determine payment responsibilities.
Claim Reconsideration Request Form: This form, used to appeal claim denials, similarly includes details about the patient and services provided, making it a parallel document in the claims process.
Dental Predetermination Request Form: It is designed to verify coverage and benefit amounts for proposed dental treatments, akin to the preauthorization section on the Guardian claim form.
Explanation of Benefits (EOB): Although different in function, the EOB provides crucial information on payment decisions and service coverage, mirroring the focus on financial responsibility found in the Guardian form.
Orthodontic Claim Form: This form is tailored for orthodontic treatments and similarly captures details about the patient, procedure, and billing information.
Insurance Verification Form: Both forms aim to confirm pertinent insurance details, helping to streamline the payment and reimbursement process.

Dos and Don'ts

Do read the instructions carefully before starting to fill out the form.
Do use the correct date format (MM/DD/YYYY) for all date entries.
Do include all necessary personal information, such as names and addresses.
Do ensure the procedure dates are accurate and match the services provided.
Do list diagnosis codes correctly to maximize claim approval chances.
Don't leave any required fields blank unless specifically instructed to do so.
Don't forget to sign and date the form before submission.
Don't use abbreviations for names or addresses, as complete information is critical.
Don't forget to attach any relevant documents, such as the primary payer's Explanation of Benefits.
Don't wait until the last minute; submit your claim as soon as possible to avoid delays.

Misconceptions

Misconceptions about the Guardian Dental Claim form can lead to confusion and delays in processing claims. Here’s a look at eight common misconceptions and their clarifications:

All fields on the form must be filled out: While it’s important to complete most fields, some specific sections allow for blanks if they don't apply, like the “Other coverage” section.
The claim cannot be submitted without a diagnosis code: Diagnosis codes should be included, but if they are not available, the claim can still be submitted without them.
Multiple claims must be submitted for multiple procedures: If the number of procedures exceeds the lines available on the form, it’s acceptable to list the remaining procedures on a separate claim form instead of submitting multiple claims.
Signature is not required for electronic submissions: A signature is still necessary, even for electronic submissions, to authorize the payment and treatment.
Primary payer's payment information must always be included: While it’s beneficial to attach the primary payer's Explanation of Benefits if applicable, it is not mandatory for all claims.
Diagnosis codes are optional: Diagnosis codes are essential in many cases and should be included where relevant to prevent issues with adjudication.
The Plan/Group Number is the same as Policyholder ID: The Plan/Group Number and Policyholder ID are separate identifiers. Ensure both are filled out accurately.
Claims submitted after treatment must include extra documentation: While some documentation may be necessary, it often depends on the specifics of the treatment and insurance requirements. Always check the specific needs for your claim.

Understanding these points can help streamline the claims process and ensure that submissions are handled more efficiently.

Key takeaways

Understanding the Guardian Dental Claim form is essential for efficient processing of dental claims. Here are some key takeaways to guide you through the completion and submission of the form:

Complete All Relevant Sections: Ensure that every applicable section of the form is filled out. This includes the policyholder's information, patient details, and the record of services provided. Leaving any fields blank may lead to delays in processing.
Accurate Diagnosis Codes: Report the appropriate diagnosis codes attached to each dental procedure. The form allows for up to four diagnosis codes, which are critical in ensuring that claims are correctly adjudicated based on the patient’s health condition.
Coordination of Benefits: If you’re submitting a claim to a secondary payer, attach the primary payer's Explanation of Benefits (EOB). Mention the primary payment amount in the remarks section to streamline processing.
Use Correct Place of Treatment Codes: Indicate the place of service using the appropriate two-digit code. This informs the payer where the services were rendered and facilitates claim processing. Frequently used codes include ‘11’ for Office and ‘22’ for Outpatient Hospital.
Signature Requirements: Both the patient and the provider must sign the form. Ensure that signatures and dates are provided, as missing signatures can lead to claim denials.
Double-Check for Accuracy: Before submitting, review the entire form for accuracy. Small mistakes in names, dates, or codes can result in significant delays or denials of coverage.

By keeping these tips in mind, you can enhance the likelihood of a smooth claim review process. Properly completing and using the Guardian Dental Claim form ultimately helps in obtaining timely dental care reimbursement.

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