Dental Prime and Dental Complete Broker Services (Groups 2-50)

PW_E167926
 
Group post-sale questions?  Call Employer Services at (877) 567-1799.
Individual pre-sale questions?  Call (877) 567-1807, Mon-Fri 8am – 8pm EST.
Individual dental post-sale questions?  Call (877) 604-2158, Mon-Fri 8am – 8pm EST.
Individual vision  post-sale questions?  Call (866) 723-0515
Individual billing questions? Call (855) 881-7217
Individual commission payment questions?  Call (877) 606-3409 or email BCBSGACommissions@bcbsgadentaladmin.com  
These forms apply to group only, unless noted with an *, which indicates form applies to group and individual coverage.  
Dental Prime and Dental Complete Tools 
Broker Rate Calculator

Broker Rate Calculator – Password Request Form

Online Commission Reports Tool*
Online Commission Reports User Request Form*
ACH Commission Form*
Agent of Record Assignment Form - Groups
Agent of Record Assignment Form - Individuals*
 
Pre-Sale Materials  
Employer Flier
Plan Designs (Groups 2-50)
Plan Designs (Groups 51+)
 
Group Implementation & Enrollment  
Group Master Application (for groups 2 - 50)
Submission Requirement Checklist (for groups 2 - 50)
Census Enrollment Spreadsheet
 
Member & Group Forms 
Membership Enrollment Form
Membership Enrollment Form – Spanish
Membership Maintenance Form
Authorization to Release Information*
Authorization to Release Information - Spanish*
HIPAA Designated Contact Form
Disabled Dependent/Michelle’s Law Application*
 
Claims & Additional Benefits Forms 
Dental Claim Form*
International Emergency Dental Program Flyer*
International Emergency Dental Program Frequently Asked Questions*
Extra cleaning sign up form for diabetic and pregnant members*
 
Online Services 
Online Capabilities Flier
Online Enrollment Billing Reports Request Form
Dental Employer Online Services Demo
 
Group Billing Forms 
Weekly ASO Billing Schedule
Monthly Fully Insured Billing Schedule
 

Footer Links:

© 2014 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.