Orchard - Unchanged

Paper Claims Submission

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