COORDINATION OF BENEFITS
When you have two or more insurance policies, we need to verify the coordination of benefits. This is the order that we submit the claims for proper payment. Each insurance company has their own way of establishing the correct filing order. You will need to reach out to all dental insurance companies to answer questions about the policies, record the information on this form, and return the form completed correctly to avoid any out of pocket expenses. Before you call, please have the following information available:
* Subscriber’s legal name and date of birth
* All dependent’s legal name and date of birth
* Both insurance cards/informa
* Employer(s), if applicable
* Dates coverage began
Call the Customer Service number of the insurance company, usually found on the back of the insurance card, and say: "I’m calling to update my Coordination of Benefits for the dependents on the policy. I have dental coverage with another insurance plan in addition to this one, and I want to make sure my information is up to date. What information do you need?"
They will ask you a series of questions pertaining to marital status, patient/subscriber relationships, and divorce decree stipulations (if applicable).
After giving all the information to the representative, ask them:
* Based on the information I gave you, are you the primary or secondary (or third, if applicable) insurance?
* How long will it take to update all the accounts?
* May I please have a reference number for this call and the correct spelling of your name?
The Insurance Department of Forest Orthodontics and Pediatric Dentistry will call the insurance companies to verify the accounts have been updated to avoid any issues when submitting a claim. If any issues arise when we submit a claim, we can refer to the representative’s phone call to clear up the issues.
If this information is not provided prior to your upcoming appointment, we will collect the out of pocket expenses for the pediatric dental services provided on that day and will submit the claim once we receive the COB information. Thank you for your cooperation!
Primary Insurance Company:
Representative’s Name and Reference Number:
Subscriber and Relationship to Patient:
Secondary Insurance Company:
Representative’s Name and Reference Number:
Subscriber and Relationship to Patient:
Third Insurance Company:
Representative’s Name and Reference Number:
Subscriber and Relationship to Patient:
Responsible Party Signature:
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Date:
Print Name: