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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 8am – 8pm EST.
Individual dental post-sale questions?  Call (866) 956-8607, 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 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 
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*
Contact Us
 
Pre-sale Materials 
Employer Brochure
Small Group (2-99) Plan Designs
Large Group (100+) Plan Designs
 
Group Enrollment and Implementation Forms 
Group Master Application (for groups 2-99)
Submission Requirement Checklist (for groups 2-99)
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 Dependents/Michelle's Law Application*
 
Claims & Additional Benefits Forms 
Dental Claim Form*
International Emergency Dental Program Flier*
International Emergency Dental Program Frequently Asked Questions*
Extra cleaning sign up form for diabetic and pregnant group members
Extra cleaning sign up form for diabetic and pregnant individual members*
 
Online Services 
Online Capabilities Flier
Online Enrollment Billing Reports Request Form
Dental Employer Online Services Demo
 
Group Billing Forms 
Automated Fully Insured ACH Authorization Form
Automated ASO ACH Authorization Form
 
Commission Forms 
ACH Commission Form*
Online Commission Reports User Request Form*
©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