Filing Dental Claims

BlueDental participating dental providers and some out-of-network providers will file claims for you, but you may be required to submit a claim form for services received from an out-of-network dentist. Please check with your dentist for clarification, as out-of-network providers are not required to submit claims on your behalf.

How do I submit a claim?

Complete a separate claim form for each covered member who received services and each provider. You must file your claim within one year after the last day you received services; claims filed after one year aren’t eligible for payment.

Enclose a signed letter with your claim that includes the following:

• A daytime phone number
• Your BlueDental member ID number (the number is printed on your member card)
• Information about other dental coverage you may have

Enclose an itemized statement of services received from your dentist in English or a statement in a foreign language with an English translation on the provider’s stationery. The provider statement must include all of the following:

• Provider’s full name and address
• Patient’s name
• Date(s) you received service(s)
• The charge for each service in U.S. currency
• Description of each service using the correct Common Dental Terminology code (CDT)
• Where you received the service

A claim without a provider statement will be denied. Statements that you prepare, cash register receipts, receipt of payment notices, or balance due notices will not be accepted.

Send your claim to Florida Combined Life, P.O. Box 69436, Harrisburg, PA 17106-9436. 

Payment of claims during grace period

If you are enrolled in an individual BlueDental Choice or BlueDental Copayment Q or QF plan, and do not pay your premium on or before the due date, you are entitled to a grace period. For individual Affordable Care Act (ACA) plans, we allow a three-month grace period to pay each premium after the initial premium. The grace period for non-ACA Individual and group plans is 31 days.

If you purchased your BlueDental plan directly from Florida Blue (Off-Marketplace plans) or you purchased a plan On-Marketplace but you do not receive a subsidy, your coverage will be active during this three-month grace period. To keep your coverage, you’ll need to pay your premium before the end of the three months. If you don’t, your policy will be canceled. You’ll lose coverage back to the last paid through date and be responsible for any claims for services you received after that date.

If you purchased your plan On-Marketplace and you receive a subsidy to help pay for your coverage, claims will be paid during the first month of the grace period for all eligible dental services rendered. During the second and third months of the grace period, claims may pend and be denied if past due premiums are not received.

If the premium is not received prior to the end of the grace period, the policy will be canceled.

Explanation of Benefits

Each time you visit the dentist, we will send you an Explanation of Benefits (EOB) statement. An EOB is a statement that explains how we processed a claim based on the services performed. It is not a bill.

The EOB includes:

• The date you received the service
• The amount billed
• The amount covered
• The amount we paid
• Any balance you’re responsible for paying the provider
• How much has been credited toward any required deductible or annual maximum
• Each time you receive an EOB, review it closely and compare it to the receipt or statement from your dentist. Learn how to read your EOB here. You can choose paperless EOBs by selecting the option in your account portal.

Timeframe for claim determination

If we receive all the information we need to process your claim, we’ll send you an EOB within 20 days (electronic claim) and 40 days (paper claim) of receiving your claim. However, if we need more information or are unable to make a decision due to circumstances beyond our control, we’ll extend our response time for 15 days. We’ll let you know within 30 days why we’re extending our response time and when you can expect our decision. If we need more information, you’ll have at least 45 days to provide it to us.

Denials

If any of the services on your claim are denied, the EOB will explain why. If you disagree with our decision to deny your claim or request for coverage, please call us for help. If you’re not satisfied with the information you receive and you’d like to pursue a claim for coverage, you may request an appeal.

There are certain cases when a claim for dental services may be denied even after you’ve received the service and the claim has been paid. Some examples include:

• Using an expired Florida Blue membership card to get services. If the provider doesn’t verify eligibility over the phone or electronically, the service may be denied when the claim is filed.
• Not getting preauthorization for a service that requires it.
• Getting a service that’s not a benefit of your plan.

The best ways to prevent denials are to pay your premiums on time, talk to your providers about what’s covered before you get services and know your BlueDental plan benefits.

Retroactive claim denials

Florida Blue doesn’t request refunds for claims paid when a member’s termination date is adjusted retroactively unless the enrollee is ending their BlueDental plan and enrolling in another insurer’s dental plan. In all other circumstances, once a termination date is placed in a member’s record, claims are processed or denied based on that date. However, if a member ends their BlueDental plan and enrolls in another insurer’s plan, Florida Blue will request a refund from the provider for any claims paid after the retroactive termination date. The provider is responsible for refunding the member for payment of any cost shares. Providers are responsible for billing the new insurance company for any covered services that you receive and were paid for after the retroactive enrollment date. Florida Blue instructs providers to collect only the copayment or coinsurance for the covered service to reflect the member’s cost-sharing obligation for their plan. Such an adjustment may result in the member making additional payments to the provider. Florida Blue advises providers that any refund or credit for any excess cost sharing must be provided (or begin to be provided in the case of a credit) within 45 calendar days of the date of discovery of the excess cost sharing. In the case of premium paid for or on behalf of the enrollee, any refund or credit for any premium paid for or on behalf of the enrollee will be provided (or begin to be provided in the case of a credit) by Florida Blue within 45 calendar days of the date of discovery of the excess premium paid.

If you have questions about filing claims, call us at 888-223-4892, Monday - Friday, 8 am - 8 pm ET.

Prior Authorization

Prior authorization is an approval process to make sure that certain treatments, procedures, or devices meet payment determination criteria before the service is rendered. If you’re under the care of a Florida Blue participating dental provider or in-network provider, the provider will get approval for you.

Prior Authorization for Nonurgent Dental Care

If your request for prior authorization isn’t urgent, Florida Blue will respond to your request within a reasonable time that’s appropriate to the clinical circumstances of your case. We’ll typically respond within 15 business days of receiving your request. We may extend our response time for an additional 15 business days if we can’t respond within the first 15 business days or if it’s due to circumstances beyond our control. If this happens, we’ll let you know before the end of the first 15 business days. We’ll tell you why we’re extending our response time and when we expect to make a decision. If we need more information, we’ll let you know and give you at least 45 business days to provide it to us.

Prior Authorization for Urgent Dental Care

Your care is urgent if the time periods that apply to prior authorization for nonurgent care:

• Could seriously risk your life or health or your ability to regain maximum function, or
• In the opinion of your doctor or dentist, would subject you to severe pain that can’t be adequately managed without the care that’s the subject of the request for prior authorization.

Florida Blue will respond to your request for prior authorization of urgent care within 24 hours of receiving the information we need.

If we don’t receive enough information to help us make a decision about your request, we’ll let you know within 24 hours. We’ll let you know what we need and give you at least 48 hours to provide it to us.

You have the right to appeal

If you disagree with our decision, you may appeal.