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Claim Filing Directions

Ortho Information

Welcome to DCUE Dental Reimbursement Fund

We are located at 7373 W 147th Street, Suite #107, Apple Valley, MN 55124

Phone: 952-432-4033 Fax: 952-891-6492

DCUE Dental Reimbursement Notes for 2013 – 2014

Get information from the web at www.dcue.org (dental tab) for our Plan Guidelines, downloadable Claim Forms and downloadable 2012-2013 & 2013-2014 Enrollment Forms. You can also send an email: dcuedental@gmail.com with any questions.

ENROLLMENT FORMS

We are requesting a new Enrollment Form for 2013-2014 Plan Year. The new Enrollment Form is purple and can also be downloaded from our webpage. If you did not fill out a Salmon colored Enrollment Form for 2012-2013 you will need to do so in order to be reimbursed for treatment dates between 9/1/2012 – 8/31/2013. If in doubt, email us at dcuedental@gmail.com and we will check for you.

Without a new enrollment form on file, we will not be able to process any claims. Be sure to enroll all members of your family that you want coverage for … no cost to you to do this!

PLEASE write legibly!

CLAIM FORMS

Please use the new Claim Form attached. As of December 1st, 2012 we no longer accept old forms! You MUST include your correct ID number on claim forms and attach ALL NECESSARY supporting documentation. The new form no longer requires your dental provider to sign. Without compete claim forms and documentation, your claim will be returned.

Completing the new Claim Form:

Section 1: Only top line of boxes unless both are employees qualified for the dental plan

Section 2: NAME of patient!!! Legible -- only ONE person per claim form

Date of treatment only ONE date per claim form

Amount Paid by Participant – actual amount paid out of pocket – after refunds, discounts, other insurance

Date Ortho Payment Made and Amount – self explanatory

Section 3: MUST HAVE AT LEAST TWO BOXES CHECKED!

1st 2 boxes checked if no other insurance

3 boxes checked if yes to other insurance (1st, 3rd & 4th)

Name/Address/Phone of Provider – Phone number is critical!

Your Signature and Date

CHECKS AND EXPLANATION OF BENEFITS

We issue one check for each claim – no longer combining multiple claims into one check.

Check is the upper 1/3 of the sheet mailed to you; the EOB is the lower 2/3 of the sheet.

EOB states remaining benefits for the specified claimant.


File list
Updated  7/13/2013 /  By  dcue Admin