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  • Ameritas Dental Claim Form 2016

Get Ameritas Dental Claim Form 2016-2025

TREATMENT RECORD Tooth number, letter, DESCRIPTION OF SERVICES quadrant or arch Surfaces (including x-rays, prophylaxis, materials used, etc) CDT ADA Procedure Code Date Service Performed Month Day Year Fee 25. Remarks for unusual services 26. Total fee charged 27. CERTIFICATION: I hereby certify that the services listed above have been performed on the dates indicated and that the fees submitted are the fees I have charged and intend to collect for those purposes. 28. Address where t.

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How much time do I have to submit a claim? We recommend that claims be submitted as soon as possible, as dental plans have a timely filing clause. Unless otherwise noted in your certificate, active insured members must submit claims to us within 90 days of the date of service.

Ameritas will let you know if additional information is needed. Many claims can be processed using the narrative or claim remark field to provide replacement dates or pocket depths. Ameritas will accept up to 250 characters in this field. The Ameritas Payor ID Number is 47009 and 72630 (NY).

Group Claim Office / P.O. Box 82520 / Lincoln, NE 68501-2520 / Toll Free 800-487-5553 / Fax 402-467-7336 / Web ameritas.com Ameritas' payer ID for electronic claims is 47009. Missing or incomplete information will slow down claims processing.

our payer ID: 47009 We also have services for electronic attachments such as x-rays and radiographs.

If all or part of a claim is denied, you may appeal or submit a written request for a review of our benefit decision within 180 days after receiving our notice of the denial.

One-time new user registration to set up your User ID and password. (You will need a source code found on at the top of an EOP Statement (claim explanation) issued by us within the last 15 months.)

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232