Anthem Blue Cross : Dental Prime and Complete Employer Services

Anthem BlueCross of California

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Anthem Blue Cross : Dental Prime and Complete Employer Services

PW_E169220

Post-sale questions? Call Employer Services, a division of Customer Service, at 877-567-1799. Press 1 for Billing, 2 for Enrollment, 3 for Group Administrator Help Line.

Dental Prime and Complete Employer Tools

(log on to access online enrollment and billing reports)

Group Implementation & Enrollment

Group Master Application (for groups 2-50)

Sold Case Checklist (for groups 2-50)

Census Enrollment Spreadsheet

Dual Option Dental Enrollment Verification Form

Group Administration Manual

Member & Group Forms

Membership Enrollment Form

Membership Enrollment Form – Spanish

Membership Enrollment Form – Chinese

Membership Enrollment Form – Vietnamese

Membership Maintenance Form

Authorization to Release Information

Authorization to Release Information - Spanish

HIPAA Designated Contact Form

Disabled Dependent/Michelle’s Law Application

Cal-COBRA Continuation Coverage Election Form (for groups of less than 20)

Additional Benefits Forms

International Emergency Dental Program Flier

International Emergency Dental Program Frequently Asked Questions

Extra Cleaning Sign-Up Form For Diabetic and Pregnant Members

Online Services

Online Enrollment User Request Form

Billing Reports Online User Request Form

Billing Reports Online Change Request Form

Group Billing Forms

Monthly Fully Insured Billing Schedule

Weekly ASO Billing Schedule

Automated Fully Insured ACH Authorization Form

Automated ASO ACH Authorization Form

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2011 Anthem Blue Cross.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.