File an Appeal

You, your designated representative or your dentist may submit an appeal of a denied claim or service. If you choose to submit the appeal, please note that information from your Dental Explanation of Benefits (DEOB) is required to complete the following form to begin the Appeal Process. If you do not have a DEOB, contact your dentist or contact Customer Service at 1-866-984-2337.

Fields with asterisks ( * ) are required.

Relationship to Patient *I am the...

*Explanation of Appeal

Appeal Information

*Claim Number (ICN):

Dental Office or Name of Dentist:

*Provider Number:

Dental Office Phone:

*Procedure Code

(D1234)

*Service Date

(mm/dd/yyyy)

*Provider's Charge

Tooth Number/

Range/

Surfaces

Patient Information

*Rank:

*Branch of Service:

*First Name:

Middle Initial:

*Last Name:

*ID Number

Social Security Number:

- OR -

*Date of Birth:

*Phone:

*Email:

*Street Address 1:

Street Address 2:

*City:

*State:

*ZIP Code:

Attachments Please enter patient Social Security Number before uploading attachments. Once you have uploaded attachments, you will not be able to edit the SSN.

*I acknowledge and agree that by selecting this box I am electronically signing this document and intend for it to be my legal signature. I represent that all information in this document is correct to the best of my knowledge.

File an Appeal

Tooth Number or Tooth Range

Quadrant