Forms and documents Alaska

Handbooks

• Delta Dental of Alaska Provider Handbook - guide for dental office staff on how to work with us
• Understanding NPIs - Understanding how we use your National Provider Identifier

Claims and payments

Find out how to file fees and submit claims electronically

• Claims form - Advise your patients to log in to their Member Dashboard to access the ADA claim form
• ERA form - Enroll to receive Electronic Remittance Advice (ERA)
• Refund submission form - Request refunds for overpayment
• Electronic Remittance Explanation Codes - details about Claims Adjustment reason codes, also called HIPAA Claims Adjustment Reason Codes - Facets
• Sample EOPs - See what an explanation of payment (EOP) looks like
• Sample EOBs - See what an explanation of benefits (EOB) looks like

Authorizations

• Member Disclosure Authorization form - Authorizes the release of health information

Alaska credentialing

• Alaska Dental Credentialing Application - Join the Delta Dental network
• Alaska Dental Recredentialing Application - Continue being a part of the Delta Dental network

Miscellaneous

• Notice of Address Change and Additional Location - Let us know if you have changed addresses or added a location
• Notice of Sale of Practice Form - Let us know if you have sold your practice

• Provider diversity data - submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
• Clinic diversity data - submit diversity, equity, and inclusion focused information for contracted clinics/facilities