Edit, Download, and Sign the Prominence Health Plan Pre-Treatment Estimate Form
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How do I fill this out?
Filling out the form correctly is crucial for timely processing. Begin by providing your personal and membership information. Follow the prompts for detailing the dental procedures required and submit any additional information as needed.
How to fill out the Prominence Health Plan Pre-Treatment Estimate Form?
1
Begin by entering your personal details including name, address, and date of birth.
2
Clearly indicate the dental procedures you are seeking estimates for on the form.
3
Provide the dentist's information including name and license number.
4
Check all missing teeth and document the respective tooth numbers.
5
Review the completed form for accuracy before submission.
Who needs the Prominence Health Plan Pre-Treatment Estimate Form?
1
Dental insurance members who require prior approval.
2
Patients seeking clarity on treatment costs before procedures.
3
Dentists needing to submit estimates for their patients.
4
Healthcare providers coordinating with insurance companies.
5
Individuals comparing costs across different treatment options.
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What are the instructions for submitting this form?
To submit the completed form, email it to PHPPlusCard@uhsinc.com or fax it to (775) 770-9001. Ensure all information is complete and accurate to facilitate prompt processing. If you prefer to mail the form, send it to Prominence Health Plan, Medicare Resolution Desk, 1510 Meadow Wood Lane, Reno, NV 89502.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, it is essential to submit this pre-treatment estimate form before scheduling any dental procedures to ensure coverage. Keep track of any changes in your insurance plan or provider requirements during these years.
What is the purpose of this form?
The purpose of this form is to provide a clear estimate of dental procedure costs to members of the Prominence Health Plan. This ensures patients have transparent information regarding their financial obligations before treatments begin. It helps streamline the approval process between dental providers and insurance companies.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: Includes the first and middle initials of the member.
- 2. Member Address: Complete mailing address of the member.
- 3. Member ID Number: Unique identifier for the insurance member.
- 4. Patient's Coverage Status: Indicates if the patient is covered by another dental plan.
- 5. Provider Information: Details about the treating dentist including NPI and license numbers.
- 6. Tooth and Procedure Codes: Specifies the teeth and associated procedure codes related to dental work.
What happens if I fail to submit this form?
Failure to submit this form correctly can lead to delays in treatment and denial of insurance coverage. It is critical that all necessary fields are filled out accurately to avoid any issues.
- Claim Denial: If the form is not filled out correctly, your claim may be denied by the insurance provider.
- Delayed Treatment: Incomplete forms can lead to delays in receiving dental treatments or approvals.
- Extra Costs: Not submitting the form may result in unexpected out-of-pocket costs for the patient.
How do I know when to use this form?
- 1. Major Dental Procedures: Use this form for surgeries, implants, and other significant dental work.
- 2. Orthodontic Treatments: Applicable for orthodontic procedures requiring estimates for insurance.
- 3. New Treatments: For any new treatment options your dentist discusses, this form is required.
Frequently Asked Questions
How do I use this form?
Fill out your personal details and the specific dental procedures required, and submit to your provider.
Can I edit the PDF form?
Yes, you can easily edit the PDF using PrintFriendly's editing tools.
How do I save my changes?
After editing, you can download the file to save your changes.
Is this form necessary for all dental procedures?
This form is necessary for procedures requiring a pre-treatment estimate.
How can I share the filled form?
You can share the completed form through email or social media directly from the platform.
Can I print the form after editing?
Yes, you can print the PDF after making your edits.
What should I do if I make a mistake?
You can go back and make any edits using PrintFriendly's tools.
Who approves the treatment estimate?
The dental insurance provider reviews and approves the submitted estimate.
Do I need to fill out every field?
Yes, make sure to fill in all required fields for proper processing.
What if I have questions about the form?
Contact your dental provider for assistance with the form.
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