Forms & Disclosures
When accessing or downloading online forms, you agree to release, indemnify and hold harmless Ameritas Life Insurance Corp. and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current Ameritas forms on file.
ADA Dental Claim Form
Some states require you to use the ADA Claim Form for paper submission of dental claims. If you have services performed in one of the following states, you must use the ADA form: GA, ID, IL, IN, KY, LA, MD, MN, MO, MT, NC, ND, NJ, NV, NY, OH, OK, SD, TN, TX, VT, WI, WY. This listing of states is subject to change due to state regulations.
The Iowa Supreme Court has determined that Iowa law does not allow dental insurers to set maximum fees on services that the insurer does not cover or reimburse. As your insurer or administrator, we will have no involvement in setting the fee for such services, and any questions or concerns you may have about such fees should be directed to your dentist.
|DenteMax, LLC||Leases dental network to Ameritas, Provider credentialing|
|Government Employees Health Association (GEHA) Connections Dental Network||Leases dental network to Ameritas, Provider credentialing|
|EyeMed, LLC||Leases vision network to Ameritas, Provider credentialing|
|P&R Dental Strategies, LLC||Utilization review of dental claims|
|Zelis||Leases dental network to Ameritas, Provider credentialing|
You have the right to appeal our claims determination(s) or appeal an apparent lack of activity on a claim you submitted.