Anthem Blue Cross : Dental Prime and Complete Broker Services

Dental Prime and Complete Broker Services

PW_E169273
(applies to Small Groups 2 –50 effective prior to 10/1/2015. Large groups call Broker Services at 800-678-4466)  
 
Post-sale questions? Call Broker 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 Tools 
Online Commission Reports Tool

Online Commission Reports User Request Form

ACH Commission Form
Agent of Record Assignment – Group
Agent of Record Assignment – Individual
Broker Reference Manual
 
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
Online Enrollment Billing Reports User Request Form
 
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
Disabled Dependent/Michelle’s Law Application
Cal-COBRA Continuation Coverage Election Form (for groups of less than 20)
Off Exchange Change 2015 Fill FR 02 15.pdf
OHIX Dental Employer App Fill FR 10 14.pdf
OHIX Dental Employee App Fill FR 10 14.pdf
Off Exchange Change 2015 Prt FR 02 15.pdf
OHIX Dental Employer App Prt FR 10 14.pdf
OHIX Dental Employee App Prt FR 10 14.pdf
 
Claims & Additional Benefits Forms 
Dental Claim Form
International Emergency Dental Program Flier
International Emergency Dental Program Frequently Asked Questions
Extra Cleaning Form for Pregnant and Diabetic Members
 
Group Billing Forms 
Monthly Fully Insured Billing Schedule
 
Benefit Summaries 
CA SG Classic Active EPO Basic Plans
CA SG Classic Active EPO Major Plans
CA SG Classic Passive EPO Basic Plans
CA SG Classic Passive EPO Major Plans
CA SG Enhanced Active Plans
CA SG Enhanced Passive Plans
CA SG Value Active Plans
CA SG Value Passive Plans
CA SG Voluntary Active Plans
CA SG Voluntary Passive Plans
 
Benefit Summaries for New SG Complete Plans (1-20) 
Classic Plans (1-13):  
CA SG New Classic Active Basic Plan 1
CA SG New Classic Active Basic Plan 2
CA SG New Classic Active Major Plan 3
CA SG New Classic Passive Basic Plan 4
CA SG New Classic Passive Basic Plan 5
CA SG New Classic Passive Basic Plan 6
CA SG New Classic Passive Major Plan 7
CA SG New Classic Passive Basic Plan 8
CA SG New Classic Passive Basic Plan 9
CA SG New Classic Passive Basic Plan 10
CA SG New Classic Passive Basic Plan 11
CA SG New Classic Active Basic Plan 12
CA SG New Classic Active Basic Plan 13
 
Enhanced Plans (14-19):  
CA SG New Enhanced Active Basic Plan 14
CA SG New Enhanced Active Basic Plan 15
CA SG New Enhanced Active Basic Plan 16
CA SG New Enhanced Active Basic Plan 17
CA SG New Enhanced Active Basic Plan 18
CA SG New Enhanced Active Basic Plan 19
 
Voluntary Plan (20):  
CA SG New Voluntary Active Major Plan 20
 

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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.