Get Dental Appeal Form

This guide provides a detailed walkthrough for completing the Dental Appeal Form online. Ensuring that you fill out the form accurately is essential for a successful appeal of your dental benefit claim.

Follow the steps to complete your Dental Appeal Form online.

1. Click ‘Get Form’ button to access the Dental Appeal Form and open it for editing.
2. In the first section, enter the patient’s name, ensuring that all details are accurate and match the records held by GEHA.
3. Select the dental plan from the provided options: Connection Dental Federal (FEDVIP) or Connection Dental Plus. Indicate your Plan ID number accurately.
4. Provide the claim number(s) related to the appeal. Include all relevant claim numbers for clarity.
5. Fill in your name, and indicate your status as either a covered person, patient, or authorized representative. If acting as an authorized representative, explain your relationship to the patient.
6. Enter your complete mailing address, including street address, city, state, and ZIP code.
7. Include your phone number and email address for GEHA's response to reach you easily.
8. Select how you prefer to receive a response — either by letter or email.
9. Provide a detailed explanation of why you believe the initial decision was incorrect, referencing specific benefit provisions from your plan brochure. Use additional sheets if necessary.
10. Attach any supporting documents that may strengthen your appeal. This may include dentist letters, provider narratives, X-rays, and explanation of benefit forms.
11. Confirm that all the information provided is correct by reviewing it thoroughly.
12. Sign and date the form before submitting it. Once completed, you can save changes, download, print, or share the form as needed.

Take the next step in your appeal process by completing and submitting the Dental Appeal Form online.