Dental claim fee schedule

If your dental insurance card doesn't look like this, please visit this page for more information.

Steps for completing a dental claim by using the paper form
You can file a dental claim to receive benefits for over 400 routine and extensive procedures, including:

  • Cleanings
  • Fillings
  • Sealants
  • Tooth removal
  • Crowns
  • Dentures

Use these steps to guide you through the process of filing a dental claim. If you need to submit an accident insurance or vision rider claim as well, download the accident claim and vision claim forms.

  1. Download the dental policy claim form.
  2. Have the dentist who treated you complete the form in its entirety.
  3. Sign and date the Authorizations section.
  4. Carefully review your forms to ensure all required sections are completed, including all areas where a signature and date are needed.
  5. Your dentist may submit the claim electronically. Alternatively, you can fax your claim to 1-855-855-1575 (Attn: Dental Claims) or mail it to P.O. Box 30507, Salt Lake City, UT, 84130.
  6. All dental claims are processed by HealthPlanServices. To check the status of your dental policy claim, call 877-477-4065, or visit HPSClaimServices.com.