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Dental Prime and Dental Complete Broker Services

PW_E167926
(applies to Small Groups 2 –50 effective prior to 10/1/2015 and Individual Plans submitted prior to 8/15/2015. Large groups call Broker Services at 866-215-4879) 
 
Group post-sale questions?  Call Employer Services at (877) 567-1799.  
For individual plans submitted prior to 8/15/2015:  
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
 
Use the links/forms below for clients with small group plans effective prior to 10/1/2015. These links/forms apply to group only, unless noted with an *, which indicates form applies to group, as well as individual plans submitted prior to 8/15/2015.  
 
Dental Prime and Dental Complete Tools 
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*
 
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*
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 Form for Pregnant and Diabetic Members*
 
Online Services 
Online Capabilities Flier
Online Enrollment Billing Reports Request Form
Dental Employer Online Services Demo
 
Group Billing Forms 
Monthly Fully Insured Billing Schedule
 
© 2017 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.