Enrollment/Change/Waiver 030HL

Enrollment/Change/Waiver 030HL - IL

Enrollment/Change/Waiver 030HL - MA

Enrollment/Change/Waiver 030HL - MN

Enrollment/Change/Waiver 030HL - MT

Enrollment/Change/Waiver 030HL - NM

Enrollment/Change/Waiver 030HL - UT

Enrollment/Change/Waiver 030HL - VA

Enrollment/Change/Waiver 030HL - WA

Census Enrollment Template - Excel

Group Dental Claim Form

Group Dental Claim Form - ESP

Individual Dental Claim Form

Individual Vision Claim Form

EyeMed Reimbursement Form

VSP Reimbursement Form

ADA Dental Claim Form
Some states require you to use the ADA Claim Form for paper submission of dental claims. If you have services performed in one of the following states, you must use the ADA form: GA, ID, IL, IN, KY, LA, MD, MN, MO, MT, NC, ND, NJ, NV, NY, OH, OK, SD, TN, TX, VT, WI, WY. This listing of states is subject to change due to state regulations.

Group Dental/Vision Application

Group Dental/Vision Application - CO

Group Dental/Vision Application - MD

Group Dental/Vision Application - NJ

Group Dental/Vision Application - NM

Group Dental/Vision Application - NY

Group Dental/Vision Application - WA

 

Dependent Child Exception Form

Dependent Child Exception Form - ESP

Disabled Dependent Status Form

Disabled Dependent Status Form - ESP

The Iowa Supreme Court has determined that Iowa law does not allow dental insurers to set maximum fees on services that the insurer does not cover or reimburse. As your insurer or administrator, we will have no involvement in setting the fee for such services, and any questions or concerns you may have about such fees should be directed to your dentist.

Company	Functions Provided
DenteMax, LLC	Leases dental network to Ameritas, Provider credentialing
Government Employees Health Association (GEHA) Connections Dental Network	Leases dental network to Ameritas, Provider credentialing
EyeMed, LLC	Leases vision network to Ameritas, Provider credentialing
P&R Dental Strategies, LLC	Utilization review of dental claims
Zelis	Leases dental network to Ameritas, Provider credentialing

You have the right to appeal our claims determination(s) or appeal an apparent lack of activity on a claim you submitted.

New Jersey Application to Appeal a Claims Determination

Your safety is important to us. Find information about your rights regarding domestic violence privacy and confidentiality.

NY Domestic and Sexual Violence Information

NY Confidential Communications Request Form

Language Assistance Program - except California

Language Assistance Program - California