To fill out the online claim form,

Select either Statement of Services Rendered if you are creating a claim or Pre-Treatment Estimate if you are requesting a pre-treatment estimate.

Select either Yes or No for the Release and Assignment fields, which are required.

If the patient is covered by another dental plan, check Yes and complete the Additional Dental Coverage portion of the claim form when prompted later.

When asked if radiographs and models are enclosed, select No unless you have a FastAttach account with National Electronic Attachment (NEA) and know the image number(s). If you don't have a FastAttach account, you must wait for a response from the insurance company to verify that an attachment is required, then follow the online instructions for submitting one. This method dramatically reduces the number of attachments that you send. (See Sending Attachments.)

Enter any remarks to explain unusual services that may help ensure that your claim is approved or your pre-treatment estimate is accurate

Under Claim Information, provide detailed information about each procedure performed.

	If you are submitting an actual claim, you must enter a date of service (MM/DD/YYYY) for each charge line/procedure performed.
	If you are unsure of a procedure code, either search by code number or category, then click on the correct code in the list of search results to add it to the claim. (See Searching for Procedure Codes.)
	For each charge line/procedure code, Tooth or Quadrant (depending on the procedure) and Fee are required fields.
	If the claim requires more than five charge lines, click Add Charge Lines to continue. Charge lines are added in increments of five, up to 15 charge lines. Claims with more than 15 charge lines must be broken into two (or more) claims.

When you have entered all charge lines/procedures, click Continue. The Claim Form page will be displayed.

If you indicated the patient is covered by another dental plan, complete the Additional Dental Coverage Information page and click Continue. This page will not be displayed if you answered No when asked if the patient has additional coverage. To display the page, click Edit Claim on the Claim Form page, change your answer to Yes and click Continue.

Important: Do not click on any of the left-hand navigation links while creating an online claim or the claim will be deleted. To avoid losing your work, click Save at the end of the claim form and retrieve the claim later from Claims Search.