File an Appeal
Thursday, May 19, 2022
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...
- Select -
ADSM (Patient)
ADSM's Command
ADSM's Authorized Representative
Other
*
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/
Quadrant
Tooth Number or Tooth Range
Acceptable Values - single value or range
Letters A - T for Baby Teeth
Numbers 1 - 32 for Adult Teeth
Numbers 51 - 82 for Supernumerary Teeth
Examples: A, C-F, 3, 3-6, 51, 53-56
Quadrant
Acceptable Values
UR for Upper Right
UL for Upper Left
LR for Lower Right
LL for Lower Left
Examples: UR, LR
Surfaces
$
$
$
$
$
$
$
$
$
$
Patient Information
*
Rank:
*
Branch of Service:
- Select -
Army
Coast Guard
Air Force
Marines
Navy
NOAA
Space Force
*
First Name:
Middle Initial:
*
Last Name:
*
ID Number
Social Security Number:
- OR -
Benefits Number:
Benefits Number - 11-digit number listed on the back
of the member's CAC card (see below).
*
Date of Birth:
*
Phone:
*
Email:
*
Street Address 1:
Street Address 2:
*
City:
*
State:
- Select -
AA
AE
Alaska
Alabama
AP
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
US Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*
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.
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