Fax: 402-467-7336
Group Claims
PO Box 82520
Lincoln, NE 68501

Dental Claim Form

Claims
Usually your provider will submit a claim for you. If you are responsible for submitting a claim, here are some helpful tips:

• If the provider gives you a statement to submit, complete only the top portion (Part 1) of a claim form with the patient and member information. Attach a copy of the statement to the claim form and submit to us.
• Each patient needs his or her own claim form.
• Missing or incomplete responses on claim forms may cause delays in processing a claim.

For additional help, please refer to the "Tips to Speed Claim Processing" located on the second page of the claim form.

Pretreatment Estimate of Benefits
A Pretreatment Estimate of Benefits lets you know in advance what your benefits will be before having the services performed. Before beginning a course of treatment, have your provider estimate the charges and submit for a pretreatment estimate. This will eliminate misunderstanding and let both you and your provider know what the benefit plan will pay. If your dental coverage terminates for any reason during treatment, only the procedures performed before the dental coverage was terminated will be eligible for payment. You should review your certificate for additional information regarding your coverage.

We recommend a pretreatment estimate be submitted for all anticipated work that you consider expensive.