PEHP does accept paper claims if they are on the ADA J430D 2012 claim form, are type written and include the following information:
- BOX 48 - Billing Dentist name and address
- BOX 49 - Billing entity NPI
- BOX 51 - SSN or TIN
- BOX 53 - Treating Dentist Name (PEHP will pay the treating Dentist)
- BOX 54 - Treating Dentist NPI
- BOX 56 - Address where services were preformed
If this information is not completed on your ADA J430D 2012 claim form your submission may be rejected.
Paper claim submissions should be mailed to:
PEHP
Attn: Claims
560 East 200 South
Salt Lake City, UT 84102-2004