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Dental Bulletin - Fall 2019: Using the Corrected Dental Claim Form

In reviewing your claims, PacificSource may occasionally request additional information and/or x-rays. In these cases, please use the corrected dental claim form available on our website. If you’re asked for additional information, you don’t need to submit a new claim—just complete the corrected claim forms and send it to us. 

If you’re making a change to the CDT code, please include chart notes to support the change. You’ll find corrected claim form at PacificSource.com/provider/forms-and-materials .