Human Resources

Submit a Delta Dental Claim

Follow the below steps to submit a Delta Dental Claim:

1. Download the claim form for your Delta Dental plan.
   • You can login to your online account to find claim forms.
   • Download the Delta Dental PPO Claim Form
2. Complete the patient and subscriber information on the form.
3. Provide a detailed receipt or document provided to you by the dentist that includes:
   • Dentist's name, address, and phone number
   • Date each service was performed
   • Description, procedure code, and fee of each service performed
   • List of affected teeth
   • Total cost of services performed
   • Dentist's National Provider Identifier (NPI)
   • Dentist's Tax Identification Number (TIN)
   • State license number
   • Specialty code
     • NOTE: if any information above is missing from the document you receive from your dentist, enter it onto the claim form.
4. Make copies of the completed claim form and Statement of Treatment or detailed receipt for your records.
5. Mail the original copies to the address printed on the claim form.