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Forms & Dental Office Resources


General Forms & EFT Enrollment*


*Note: Additional forms, including claim forms, are in Benefits Connection, your online "patient portal." Click here to register for a Benefits Connection account.

 

Claims Forms*

*Note: The prior-authorization charts apply to the contract and state in which the contract was issued. If you are a Connecticut dentist seeing a New Jersey insured patient, you will need to use the New Jersey prior-authorization chart. If you are a New Jersey dentist seeing a Connecticut insured patient, you will need to use the Connecticut prior-authorization chart.

*Note: Delta Dental of New Jersey will accept diagnostic quality photographs in lieu of stone models for prior authorization of medically necessary orthodontic treatment plans for children covered under Affordable Care Act plans in New Jersey and Connecticut. Diagnostic quality photographs should be consistent with the photographic requirements of the American Board of Orthodontics and include three facial photographs (profile, frontal, and smiling), and five intraoral photographs (frontal, right lateral, left lateral, and maxillary and mandibular occlusal). Photographs should be of sufficient quality to support the determination of medical necessity.


Credentialing Forms*
*These forms are located in Benefits Connection.


Compliance Information



Radiographic Submission Requirements

Click here for the Required Documentation Chart.

Participation Information

The Participating Handbook is in Benefits Connection.


Update your Office Information
Please contact us immediately of any changes to the following:

 

 

Resources