Dental Plans

All Dental Plans

ACE - AMERICAN CONSUMER EXCELLENCE
ADROIT HEATH GROUP DENTAL
CROWN DENTAL AND VISION (MFD)
GOOD HEALTH (Dental)
MFD ACE
MFD Adroit
MFD Kelsey
MFD MBA Direct
MFD Morgan White
NCD
REALM DENTAL

Claims Submission

PO Box Address: PO Box 35249 Phoenix, AZ 85021-9998

Physical Address: 8155 N Black Canyon HWY Phoenix, AZ 85021-9998

ELT PAYER ID: MBAAZ

Roles and Responsibilities

MBA primarily processes and reprocesses claims for dental insurance. In addition, MBA handles benefits and eligibility inquiries from both members and providers.

The table below serves as a guide.

ADA Claim Form

The ADA (American Dental Association) Claim Form is used by dental providers to document and submit charges to dental insurance for procedures performed to members.

Members may also complete and submit this form to their insurance company to request reimbursement for covered dental procedures.

Here are the important boxes that needs to be filled out. See images below.

Section 1: See Highlighted boxes

1. [Required] Mark the applicable box.
- - Statement of Actual services- Actual Claim
  - Request for Predetermination- Pre-D Claim
3. [Required] Company Name
- - MBA - PO Box Address: PO Box 35249 Phoenix, AZ 85021-9998
  - Physical Address: 8155 N Black Canyon HWY Phoenix, AZ 85021-9998
  - ELT PAYER ID: MBAAZ
4-11. [Only] needed if the member/patient has other dental insurance.
12 [Required] Policyholder's name and address
- - PL's name and address should be the same as what is shown in ClaimsMan.
13 [Required] PL's DOB
14 [Required] PL's Gender
15 [Required] PL's Member ID
- - Do not put in SSN. MID should reflect the MID on ClaimsMan.
18-23 [Only] needed if the patient is not the policy holder
- - Mark "Self" if patient is the policyholder; otherwise fill out all.

Section 2: See Highlighted boxes

24-32 [Required] Provider needs to fill out the information correctly. If the member is the one filling it out, they can get help from the provider or request the information for these boxes.
- - 31-32 [Required] For the fees, the fees in box 31 should match the total fee in box 32.
35 [Only] can be used for additional information that providers may give to insurances.

Section 3: See Highlighted boxes

36 [Required] If this box is only signed, payment goes to the member
37 [Required] If this box is only signed, payment goes to the provider
If box 36 & 37 are both signed, payment goes to the provider.
- - For boxes 36 & 37 the signature must be either handwritten signature or electronic "Signature on File"
  - MBA won't accept handwritten "Signature on File"
38 [Required] Place of Service. MBA only processes services renders in POS 11 or 50.
- - 11- Office Visit
  - 50
48-58 need to fill out all the boxes completely.
- - 53 [Required] Provider Signature. MBA accepts "Signature on File" if the claim is electronic; If the claim is handwritten then box 53 should have handwritten signature
  - 53 There can be a signature, but we also need the name of the provider legible to make sure that the claim is processed under the correct provider