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Anthem Dental Prime and Anthem Dental Complete Broker Services

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Group post-sale questions? Call Employer Services at (877) 567-1799. 
Individual pre-sale questions? Call (877) 567-1807, Mon-Fri 5am – 5pm PT. 
Individual dental post-sale questions? Call (855) 769-1462, Mon-Fri 5am – 5pm PT. 
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 commissions@AnthemDentalAdmin.com 
 
 
These forms apply to group only, unless noted with an *, which indicates form applies to group and individual coverage.  
 
Anthem Dental Prime and Anthem Dental Complete Tools 
Broker Rate Calculator – Password Request Form
Online Commission Reports User Request Form*
Online Commission Reports Tool*
ACH Commission Form*
Agent of Record Assignment Form - Groups
Agent of Record Assignment Form - Individuals*
 
Pre-Sale Materials 
Employer Flier
Plan Designs
 
Group Implementation & Enrollment 
Group Master Application (2-50)
Submission Requirement Checklist (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 Flier*
International Emergency Dental Program Frequently Asked Questions*
 
Online Services  
Online Capabilities Flier
Online Enrollment Billing Reports Request Form
Dental Employer Online Services Demo

Group Billing Forms 
Monthly Fully Insured Billing Schedule
Weekly ASO Billing Schedule
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use