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Download the CIGNA Dental Claim | Form -J430D that is used only to make dental claims from Cigna Dental in the event the dental office does not file claims. If the provider does, in fact, file claims for the patient, Cigna will always pay to the provider. If you must pay in advance and file your own claim, Cigna will pay to the patient what is covered under the current dental portion of the policy.

How To Write

Step 1 – Section 1 – Header Information –

  • So that the patient may receive reimbursement, complete the following information:
  • 1.Type of Transaction- (check all of the applicable boxes)
  • 2. Predetermination/ Pre-authorization Number

Insurance Company/Dental Benefit Plan Information –

  • 3. Company/Plan Name, Address, City, State, Zip Code

Other Coverages –

  • 4. Mark any boxes that apply and complete items 5-11. If there are none, leave them blank:
  • 5. Name of policyholder/Subscriber in #4 (last name, first name, middle initial and suffix)
  • 6.Date of Birth (mm/dd/yyyy
  • 7. Gender (check one)
  • 8.Policyholder/Subscriber’s Social Security Number or ID Number
  • 9.Plan or Group Number
  • 10.Patient’s relationship to the policyholder/subscriber
  • 11. Enter any other insurance Company Plan – Name, address, city, state, zip code, into the box provided

Policyholder/Subscriber’s Information –

  • 12. Enter the Policyholder/Subscriber’s name, (last, first, middle initial) Address, city, state, zip code, in the block provided
  • 13. Date of Birth mm/dd/yyyy
  • 14. Gender (check one)
  • 15. Policyholder/Subscriber’s social security number or ID number
  • 16. Plan or Group number
  • 17. Employer name

Patient Information –

  • 18. Relationship to Policyholder/Subscriber (check one)
  • 19. Leave blank (this block is reserved for future use)
  • 20. Enter the patient’s name (last, first, middle initial, suffix) Address, city, state, zip code, into the block provided
  • 21. Date of Birth mm/dd/yyyy
  • 22. Gender (check one)
  • 23. Patient’s ID/Account number, that has been assigned by the provider

Step 2 – Section 2 – Record of Services Provided – Reserved for the dentist

  • Once the patient and subscriber information has been completed, this document would be handed back to the provider so that a full examination will be recorded.
  • After the examination has been completed and a treatment plan has been discussed with the patient, authorization must be certified with signature.
  • Carefully read block number 36.- if understood and agreed, provide signature and date mm/dd//yyyy
  • Also read block number 37 to authorize payment directly to the provider – provide signature and date mm/dd/yyyy

Billing Dentist or Dental Entity –

  • Leave this section blank if the dentist or dental entity is not submitting a claim on behalf of the patient or insured
  • If the provider is filing a claim – Dentist must provide the following:
  • 48. Name, address, city, state, zip code
  • 49 – NPI
  • 50.  License Number
  • 51 Social Security Number or TIN
  • 52.Phone number
  • 52a. – Any additional Provider ID

Ancillary Claim/ Treatment Information as well as Treating Dentist and Treatment location information must all be reserved for the dentist to complete and sign, prior to payment.

Once all of the information is completed, submit for payment, either to the subscriber or the provider, depending upon who submits the claim, dentist or subscriber.

 

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