Submit X-rays and Documentation

Use this tool when:

• You submitted a claim using a paper form or the online claims submission tool in the Dentist Connection
• You received a request for additional information to process a claim
• You need to submit a document so we can process your patient’s claim

Is your documentation clearly marked?
Supporting documentation must be clearly marked with the appropriate identifying information, including:

• Patient name
• Date of service
• Treating dentist name
• Claim number (if applicable)