Ada J430 Form 2012-2024

Ada J430 2024 Form: What You Should Know

Item 7 — Medical Payments to J430D If your claim is subject to a fee agreement with the dentist, it is the dental claim letter number that will be attached to your letter that will contain the full number of your payment form. If you have medical costs associated with your claim, you should submit a claim letter by mail. However, if your health plan requires a payment directly to the dental facility where the services were provided, you may request this payment be sent by mail by following these instructions. You must attach copies of your prescription, if applicable. For example, if your medical expenses are related to asthma, you may attach a copy of your prescription, stating the names and amounts of all medications, including inhalers. Attach one copy each of the following: · Medical billing records for J430D Dental Services J430D Dental Services is a Dental plan, which is administered by Dental Trust. · Dental Benefits and Services Plan The Dental Benefits and Services Plan (DSP) is a program administered by Janssen Pharmaceuticals, Inc. Dental Trust is the plan's administrator. These records will be located at the Dental Trust, 1160 K Street NW., Suite 800, Washington, DC 20036, or at any Janssen location. Other Dental Benefits plans are not covered by this rule. To view the medical billing records for your ADA Dental Plan click on this link to view the ADP/DBP records. If a claim is submitted to a dental facility with whom you have a current contract (see item 7 of this ADA Dental Claim Form), please ensure that all medical and/or hospital bills for the time frame covered by the contract are forwarded to the Dental Trust. The dental claims processing system will check the billing statements for these patients to determine if any reimbursement is due. Dental Trust Item 7 — Payment to J430D Dental Services or a Dental Facility: If the dentist at issue denies the payment, the Dental Trust must be notified of the denial as set forth in Rule C05-3. The Dental Trust will then forward a copy of the denial letter to the claimant. If the claimant's claim has not yet been paid, and it is discovered that the Dental Trust has withheld funds, then the claimant must contact the Dental Trust to obtain information on how to retrieve funds.

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