Delta Dental of Arizona   (Select your state)
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Arizona Dentists
 

Submit X-Rays and Documentation

Did you submit a claim using a paper form or the online claims submission tool in the Dentist Connection?

Did you receive a request for additional information to process a claim?

Need to submit a document so we can process your patient’s claim?

Use this secure web form to submit supporting claim documentation, such as narratives, X-rays or periodontal charts, to Delta Dental of Arizona.

Tips for Uploading Documents:

  • Supporting documentation must be clearly marked with the appropriate identifying information, including:
    • Patient name
    • Date of service
    • Treating dentist name
    • Claim number (if applicable)
  • Only 1 document can be uploaded at a time. If you have more than 1 supporting document for a claim, you’ll need to scan them into a single file or submit each document separately.
  • All required fields must be completed to submit the form.

Please enter information (*Required)

Email Address: *

 

Member ID: *

 

Patient (enrollee) Name: *

 

Treating Dentist License Number: *

 

Treating Dentist Name:

 

Document Type:*

Add Document To: *


New Claim – A claim submitted within the last 24 hours.
Existing Claim – A previously submitted claim that requires additional documentation.

Browse For Document: *

JPG, GIF, BMP or PDF files only.
Special characters are not permitted in document OR folder names. Example: { ' ! ( * & ^ % $ # ) / ? }

Additional Information:

   

 

 

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