Patient Information
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If member is part of a DMO, DDS, or ENP plan, you are not able to request a PTE.
Claim Information
To complete this section, you will need a copy of the patient's bill or statement. You may need to enter procedure codes, locations, and fees for service, which can be found on the bill. View the list of possible information you may need to file this claim.
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Additional Claim Information
Separate multiple tooth numbers with a comma (1, 7, 16)
Please include any non-dental procedure diagnosis codes, electronic digital attachment IDs, office discounts applied, or other comments.
Dental Claims
Upload Documents
To ensure timely processing of this claim, please upload documents associated with the patient's procedure(s).
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Required Documents
- D0220: Current dated bitewing radiographs of teeth
- D2950: Narrative of necessity and/or treatment records when decay is not evident on submitted radiographs; if diagnosis is cracked tooth syndrome, specific diagnostic tests performed
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