Dental Provider Correspondence Request

This form is used to submit your narrative and supporting documentation such as explanation of payment (EOP), clinical records, chart notes, and x-rays. Submission of this request without documentation will result in processing delays. Attach all files using the ATTACH FILES feature at bottom of form. All services are subject to eligibility and plan provisions in effect at the time services are rendered.

This form is not to be used to submit prior authorizations for orthodontic services. Please follow predetermination process.