[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-335662-105":53,"doc-detail-335662-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","highmark-blue-shield-of-northeastern-new-york-medicare-advantage-dental-receipt-reimbursement-form","Highmark Blue Shield of Northeastern New York - Medicare Advantage Dental Receipt Reimbursement Form","","This document provides a standardized Medicare Advantage Dental Receipt Reimbursement Form issued by Highmark Blue Shield of Northeastern New York. The form facilitates the request for reimbursement for dental services under qualifying plans. It specifies necessary requirements, including the submission of itemized bills and paid receipts, and mandates that claims be submitted within 12 months of service. The document also outlines contact information for the claims administrator, customer service support hours, and mandatory regulatory compliance disclosures regarding non-discrimination and language assistance services for Spanish and Chinese speakers. It serves as an essential administrative tool for policyholders to recover out-of-pocket dental expenses through the official claims process, ensuring adherence to Medicare Advantage contract stipulations and operational deadlines for processing reimbursements within four to six weeks.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/highmark-blue-shield-of-northeastern-new-york-medicare-advantage-dental-receipt-reimbursement-form/335662/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/highmark-blue-shield-of-northeastern-new-york-medicare-advantage-dental-receipt-reimbursement-form/335662.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-21",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What documentation must be attached to the reimbursement form?","Question",{"text":109,"@type":110},"You must attach a copy of your itemized bill and paid receipt for the dental services received.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What is the deadline for submitting a dental claim?",{"text":114,"@type":110},"Claims must be submitted to the administrator within 12 months from the date the dental service was received.",{"name":116,"@type":107,"acceptedAnswer":117},"How long does the reimbursement process typically take?",{"text":118,"@type":110},"Once submitted, please allow four to six weeks for the reimbursement request to be processed.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},335662,1791349227,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Medicare Advantage Dental Receipt Reimbursement  \nPlease attach a copy of your itemized bill and paid receipt. Keep a copy of all documents for your records, as copies submitted with your request will not be returned. Not all plans include dental coverage or dental allowances. If your plan does not include dental coverage or dental allowances, disregard this form. You must submit your claim to us within 12 months of the date you received the service.  \n\n| Date |  |\n| --- | --- |\n| Name |  |\n| Address |  |\n| Date of birth |  |\n\n\n| Subscriber ID |  |\n| --- | --- |\n| Dental provider’s national provider identifier (NPI)/ taxpayer identification number (TIN) |  |\n| Dental provider’s name |  |\n| Dental provider’s address |  |\n\nPlease mail to:  \nDental Claims Administrator P.O. Box 69421  \nHarrisburg, PA 17106  \nAllow four to six weeks for reimbursement. If you have any questions, feel free to contact customer service at 1-800-329-2792 (TTY 711), October 1-March 31, 8 a.m. -8 p.m., seven days a week; April 1-September 30, 8 a.m. -8 p.m., Monday-Friday.  \nHighmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.  \nHighmark BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711).  \n注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-833-735-4515 (TTY 711)。  \nY0086   22   4516 C  \n01/23  \nMX2208728","cbCaim3pNpaDRbi9","https://ap.wps.com/l/cbCaim3pNpaDRbi9","pdf",71574,"English","# Reimbursement Submission Requirements\n## Required Patient and Provider Information\n## Mailing Instructions and Customer Support\n## Regulatory and Compliance Disclosures","[{\"question\":\"What documentation must be attached to the reimbursement form?\",\"answer\":\"You must attach a copy of your itemized bill and paid receipt for the dental services received.\"},{\"question\":\"What is the deadline for submitting a dental claim?\",\"answer\":\"Claims must be submitted to the administrator within 12 months from the date the dental service was received.\"},{\"question\":\"How long does the reimbursement process typically take?\",\"answer\":\"Once submitted, please allow four to six weeks for the reimbursement request to be processed.\"}]","Highmark Blue Shield of Northeastern New York - Medicare Advantage Dental Receipt Reimbursement Form | PDF",1790011863]