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Fill Out Your Humana Dental Form

The Humana Dental Claim Form is a document used to file a claim for dental services. This form captures essential information about the policyholder, patient, and the specific dental services provided. Completing the form accurately ensures timely processing of dental claims, helping you receive the benefits you deserve. Fill out the Humana Dental form now by clicking the button below.

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Article Structure

The Humana Dental form serves as a critical tool in navigating dental insurance claims. It is essential for both patients and dentists in documenting and submitting claims for dental procedures. This form encompasses key sections that require both detailed patient information and specific transaction types, such as statements of actual services or requests for predetermination. Notably, the policyholder/subscriber section captures vital identifiers like name, address, and the subscriber ID necessary for processing. Additionally, the 'Record of Services Provided' section allows healthcare providers to detail the treatment received, including procedure dates, tooth numbers, diagnosis codes, and associated fees. Extensive instructions guide users on completing the form correctly, underlining the importance of clarity and accuracy in each entry. This ensures timely claims processing and proper coordination of benefits when multiple insurance plans are involved. Understanding how to effectively navigate and complete the Humana Dental form is crucial for securing insurance benefits and reducing out-of-pocket costs for dental care.

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/

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Form Characteristics

Fact Name	Description
Type of Transaction	The form allows marking multiple transaction types, including Statement of Actual Services, Request for Predetermination/Preauthorization, and EPSDT/Title XIX.
Policyholder Information	Submitter must provide the policyholder's name, address, and identification numbers as required in sections 12 and 15.
Diagnosis Coding	The form supports up to four diagnosis codes linked to procedures, as indicated in Item 34, which impact claim adjudication and specific procedural risks.
Place of Treatment	Submitters must indicate the treatment location using 2-digit Place of Service Codes, such as 11 for Office and 22 for Outpatient Hospital.
Authorized Signatures	Patient or guardian, as well as the subscriber, must sign the form to authorize treatment and payment direction to the dentist.
Governing Laws	State-specific forms may be governed by various local regulatory laws depending on the insurance provider and patient’s location.

Guidelines on Utilizing Humana Dental

Filling out the Humana Dental form accurately is essential for processing your dental claims efficiently. Ensure that you gather the necessary information before you begin. Start by reviewing the required fields and have the relevant details on hand to avoid delays in the submission process.

Begin with the HEADER INFORMATION: Mark all applicable boxes for the type of transaction you are submitting.
Enter the Predetermination/Preauthorization Number if applicable.
Provide the Policyholder/Subscriber Information: Enter the name, address, city, state, and zip code of the policyholder or subscriber.
Fill in the DENTAL BENEFIT PLAN INFORMATION: Include the company or plan name, address, date of birth, gender, and Policyholder/Subscriber ID.
In OTHER COVERAGE, mark whether the coverage is dental or medical. Complete the other relevant items or leave them blank if not applicable.
Complete the PATIENT INFORMATION: State the relationship to the policyholder, enter the patient’s name, date of birth, gender, and other relevant details.
Document the RECORD OF SERVICES PROVIDED: Include the procedure date, tooth number(s), diagnoses, and associated fees for each service.
Indicate any Missing Teeth Information and fill out the diagnosis code list qualifier.
Provide the AUTHORIZATIONS: Sign and date where required, confirming you understand your financial obligations for the treatment.
If applicable, complete the ANCILLARY CLAIM/TREATMENT INFORMATION for orthodontic treatments.
Lastly, fill in the BILLING DENTIST OR DENTAL ENTITY and TREATING DENTIST AND TREATMENT LOCATION INFORMATION sections, ensuring accurate details are provided.

Double-check all entries for accuracy before submission. Ensure that all necessary signatures are acquired, as incomplete forms may lead to processing delays. Once confirmed, submit the form to the designated address for processing.

What You Should Know About This Form

What is the purpose of the Humana Dental form?

The Humana Dental form is a standardized document used to submit claims for dental services provided to patients. It is essential for ensuring that both the dental practice and the patient receive appropriate reimbursement from the dental benefits provider. By filling out this form accurately, you help facilitate the claims process, allowing for timely payment for services rendered.

Who needs to complete the Humana Dental form?

The Humana Dental form must be completed by the dental care provider on behalf of their patients. The policyholder or subscriber, who holds the dental insurance, should also provide necessary personal and insurance details. This form includes sections for patient information, procedure records, and billing details that must be filled out precisely to ensure claim approval.

What information is required on the Humana Dental form?

Critical information includes the policyholder's name, address, and subscriber ID. Details about the patient, including relationship to the policyholder, must also be provided. Additionally, the description of services rendered, dates, tooth numbers, diagnosis, and associated fees are required. Incomplete submissions may lead to delays in processing claims.

How do I ensure my claim is processed quickly?

To facilitate quick processing, all sections of the form must be completed fully and accurately. It is important to provide response codes for gender, complete diagnosis codes, and ensure that the treatment and service descriptions align with the patient’s coverage. Submitting any necessary documentation, such as previous claims or explanations of benefits from other insurers, is also advisable.

What do I do if I have multiple claims to submit?

If the number of dental procedures exceeds the number of lines available on the Humana Dental form, submit an additional claim form. Ensure that each additional form contains all the required information, and refer to the original claim for continuity. This way, each procedure is documented and processed correctly without confusion.

Can the Humana Dental form be submitted for services that were not pre-approved?

Yes, the Humana Dental form can be submitted for services regardless of whether pre-authorization has been obtained. However, it is important to note that without prior approval, the claim may be subject to additional scrutiny and may result in reduced coverage or out-of-pocket expenses for the patient.

What is the role of the patient’s signature on the form?

The patient's signature serves as consent, indicating that they agree to the treatment plan and understand their financial responsibilities. It confirms that the patient authorizes direct payment of dental benefits to the dentist or dental entity. This signature is crucial for processing the claims as it legally binds the agreement between the patient and the provider.

How can I get assistance if I have questions about the Humana Dental form?

If you have questions about completing the Humana Dental form, you can visit the American Dental Association’s website for detailed guidance. Additionally, contacting the customer service department of Humana or your dental provider can also help clarify any uncertainties regarding the form and claims process.

Common mistakes

Filling out the Humana Dental form can be straightforward, but many people make common mistakes that can delay or complicate the claims process. One frequent error occurs in the header section. Individuals often fail to mark all applicable transaction types accurately. If you are unsure whether to select "Statement of Actual Services" or "Request for Predetermination," be cautious. Marking the wrong box could lead to misunderstandings down the line.

Another mistake involves the policyholder’s information. Many people forget to include the policyholder’s full name and address. This section requires complete details; an incomplete address can hinder proper processing. Additionally, when entering dates of birth, be vigilant. Dates should include the four-digit year. A simple oversight here can cause verification issues.

Under the patient information section, individuals often make the error of leaving out the Patient ID or Account Number. This information is crucial for tracking claims efficiently. If you are a dependent, ensure you clarify your relationship to the policyholder accurately. Mislabeling relationships can lead to further complications.

Moreover, there is frequent confusion regarding the procedure details. Many people overlook the need to provide specific tooth numbers and procedure codes. This oversight can lead to delays and may require further correspondence with the dental provider. Ensure each treatment is detailed correctly by checking each tooth and procedure against the plan.

Diagnosis coding is another area where errors frequently occur. If multiple diagnosis codes are applicable, individuals often forget to fill them all out or fail to match them correctly with the procedure codes. Each code is essential in establishing the context and necessity of services rendered. Make sure to cross-reference these to avoid rejection.

Lastly, some people neglect to sign the form correctly. This can seem trivial, but without a clear signature, the form is incomplete. Additionally, be aware that authorization for payment is essential. If this is missing, the claim cannot be processed as intended. Double-check that you have signed and dated the form where required.

By taking these common pitfalls into account, you can ensure that your Humana Dental form is filled out accurately. Accuracy promotes efficiency in the claims process and provides peace of mind as you navigate your dental benefits.

Documents used along the form

When dealing with dental claims, additional documents often accompany the Humana Dental form to ensure that all necessary information is provided efficiently. These forms serve various purposes such as authorizing treatment, confirming patient eligibility, or detailing services rendered. Here is a list of common documents you may encounter alongside the Humana Dental form:

Authorization Form: This document grants permission for a dentist or healthcare provider to perform specific dental treatments. It typically outlines the procedures to be performed and may require patient or guardian signatures.
Explanation of Benefits (EOB): Provided by insurance companies, this document explains what services were covered, the amount paid to the dentist, and the costs the patient is responsible for. It is commonly attached when submitting a claim to show coordination of benefits.
Patient Registration Form: Completed at the beginning of the dental visit, this form collects essential personal information from the patient, including contact details, insurance information, and health history, which can be crucial for accurate billing and treatment.
Diagnostic Records: These may include X-rays, treatment plans, or other diagnostic information. They help justify specific treatments and assure the insurance company that the procedures were necessary.
Claim Adjustment Form: If there is a need to adjust a claim due to errors or changes in treatment, this form outlines the reasons for the adjustment and the required updates to billing records.
Referral Form: If a patient is being referred to a dental specialist, this form provides details of the referral, including the nature of the treatment and necessary patient information for the specialist.
Preauthorization Request Form: This document is submitted to the insurance company before treatment begins. It seeks approval for specific procedures, ensuring that the services will be covered under the patient’s insurance plan.

Understanding these associated forms is vital. They not only streamline the claims process but also help ensure a successful outcome for both the patient and dental provider. Being prepared with the right documents can make the experience smoother and alleviate potential issues with insurance reimbursement.

Similar forms

ADA Dental Claim Form: This form serves a similar purpose as the Humana Dental form. Both forms collect detailed patient and treatment information needed for dental claims. They include sections for policyholder details, patient relationships, and billing information.
Medical Claim Form (CMS-1500): Like the Humana Dental form, the CMS-1500 is used to submit claims to insurance companies. It gathers personal information, treatment details, and billing amounts to facilitate reimbursement from health plans.
Insurance Benefits Verification Form: This document is used to verify insurance coverage, just as the Humana Dental form assesses eligibility for benefits. Both forms require information on policyholders and date of services.
Coordination of Benefits (COB) Form: The COB form, similar to the Humana Dental form, ensures that benefits from multiple insurance policies are coordinated properly. Both forms need data about other insurances and the relationship of the patient to the policyholder.
Dental Preauthorization Request Form: This form asks for preauthorization for dental treatments, paralleling the predetermination requests in the Humana Dental form. Both require submission of treatment plans and patient information.
Provider Referral Form: Used to document referrals to specialists, this form shares similarities with the Humana Dental form by requiring patient identifiers, insurance details, and reasons for referral.
Patient Registration Form: This form captures essential patient information and insurance details. It is like the Humana Dental form in its collection of demographic and policyholder data.
Claim Appeal Form: Similar to the Humana Dental form, this document is used when appealing denied claims. Both collect pertinent details regarding the original claim, treatments, and patient information.

Dos and Don'ts

When filling out the Humana Dental form, it's important to pay attention to every detail. Submitting a correctly completed form helps expedite your claim process. Here are some guidelines to consider:

Do: Carefully read the instructions provided on the form and the ADA website.
Do: Provide complete and accurate information for each section.
Do: Ensure that the name and address of the dental benefit plan are visible in the designated window.
Do: List any additional procedures on a separate form if necessary.

Don't: Skip any sections, even if some information seems irrelevant to your case.
Don't: Forget to include the correct four-digit year in all dates.
Don't: Use abbreviations for names or addresses unless specifically instructed.
Don't: Submit incomplete diagnosis codes; ensure you use the correct format for clarity.

Misconceptions

Understanding the Humana Dental form can be challenging, and there are several misconceptions surrounding it. Below are common myths and clarifications to help you navigate the process.

You need to fill out every single field. While it's important to provide comprehensive information, certain fields can be left blank if they don't apply to your situation or the instructions indicate it's optional.
Your dentist submits the claim on your behalf without any input from you. While dentists often handle the submission, you are still responsible for ensuring that all necessary information is accurate and complete.
The form is the same for dental and medical claims. There are specific sections on the form that differentiate dental claims from medical claims, so make sure to choose the right ones.
Diagnosis codes are optional. In fact, when relevant, diagnosis codes are necessary for proper claim adjudication, particularly if they impact treatment.
Only one diagnosis code can be used. The form allows up to four diagnosis codes for each dental procedure, which can be important for comprehensive reporting.
The same code is used for all dental professionals. Different provider specialty codes must be used based on the type of dental professional—like a general practitioner or an orthodontist.
If your teeth are missing, you don't need to disclose it. The form requires information about missing teeth, so it’s essential to indicate the presence or absence of any.
All fees must be covered by insurance. Patients may need to assume financial responsibility for charges not covered by their dental benefits, as noted in the authorization section.
Using the wrong address for the insurance company is okay. Claims must be sent to the correct address for the insurance company to ensure they are processed in a timely manner.
Signature and date are not critical on the form. In reality, both the patient’s and dentist’s signatures are necessary to validate the claim and will prevent delays in processing.

By clearing up these misconceptions, you can better understand how to fill out and submit the Humana Dental form correctly. Taking the time to ensure accuracy will help ensure a smoother claims process.

Key takeaways

The Humana Dental form is used to submit claims for dental services to insurance providers.
Complete all sections of the form, including policyholder information, patient data, and treatment details.
Mark all applicable transaction types at the top of the form, such as "Statement of Actual Services" or "Request for Predetermination."
Include a claim submission for any secondary insurance by attaching the primary payer's Explanation of Benefits (EOB).
Diagnosis codes for dental procedures are important and can include up to four codes to support the claims process.
Ensure that the address for the insurance provider is visible when folding the form, following the printed tick-marks.
Utilize the correct Place of Service Codes, which indicate where the treatment took place, while completing the form.

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