File a dental claim

Most providers will submit claims on your behalf, but if you need to submit your own claim, you can find the forms and tips on filing below. There are two types of insurance: PPO (Preferred Provider Organization), which most employees will have, and the less-common Fee for Service. Look at your insurance card to see which one covers you.

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How to file a PPO claim:

  • All sections must be completed to ensure quicker processing.
  • Be sure to include the following information:
    • Your name, date of birth, Social Security number (SSN) and address
    • Claimant’s name and date of birth (if other than primary insured)
    • Your member number
    • A detailed receipt for reimbursement
  • Part 2 of the form should be completed by the attending dentist, with a copy of the statement of services or pretreatment estimate attached.

Download the paper form below, then print or fax the completed document to:

dental fee imagery

How to file a Fee for Service claim

You can file a dental claim to receive benefits for more than 400 procedures.

  • Have the dentist who treated you fill out the form in its entirety.
  • Sign and date the Authorizations section.
  • Make sure all required sections are completed, including signatures and dates.
  • Your dentist may submit the claim electronically.
    • Or you can fax your claim to 1-855-855-1575 (Attn: Dental Claims)
    • Or mail it to P.O. Box 30507, Salt Lake City, UT, 84130
  • All dental claims are processed by HealthPlanServices. To check the status of your dental policy claim, call 877-477-4065, or visit HPSClaimServices.com.