April 2014

Vhi Dental
Claim Form

INSTRUCTIONS FOR SUBMITTING CLAIMS – PLEASE READ CAREFULLY
Please ensure that  ALL sections of this claim form are completed in BLOCK CAPITALS.
A new claim form must be completed for each insured person.  You should complete and sign SECTION A. Your dentist or an authorised member  of the dental practice should complete  and sign SECTIONS B and C as appropriate.
Please  note that under the  PRSI dental scheme you  may  be entitled to a FREE annual  examination in Ireland,  this will not  affect your  claims limits, please check with your  dentist if you  are eligible before completing the  claim form.
Benefits are remitted according to your table  of benefits. This can be downloaded at www.vhi.ie/downloads

OVERSEAS  COVER
If you require treatment whilst abroad,  please obtain a detailed receipt in english and submit this with your claim form. Reimbursements will be related to your selected level of cover and the individual benefits listed. Settlements  will be made in euro.
Please  note: we are only able to accept receipts that have been translated into english, so you must arrange for this to be done before submitting  them  to us. You are responsible for the cost of any translation.

ACCIDENT OR SPORTS INJURY
If you need dental treatment following an accident or a sports injury, you must inform the claims administrator within 7 days of the accident or as soon as reasonably possible. Please provide full details of the circumstances  regarding  the accident or injury

HOW TO MAKe A CLAIM
1    Complete  SECTION A of this form and bring it with  you when you go to the dentist

2    Once the treatment has been carried out, please get your dentist or an authorised member  of the practice to complete SECTION B and C of this form. Please ensure SECTION B and C are fully itemised showing all treatments received and signed as appropriate

3    Settle the bill with your dentist and get a receipt

4    Send the fully completed claim form (1 form per patient) – together with the original payment  receipts to Vhi Dental Claims

5    Your claim will be paid into your bank account  within 10 working days

Please ensure that  completed claim forms reach us within 180 days of completion of each item of treatment. Please note  that  benefits will NOT be paid in respect  of claims which arrive beyond this period.
Note:  If your dentist is in the Vhi dental Network, you can avail of dentist direct Pay. You still need to complete  SECTION A of this Claim form. You will only need to pay the dentist for any costs not covered by your policy. Your dentist will submit the claim and will be reimbursed  directly by us. If you wish to avail of Dentist Direct Pay you must phone  Vhi Dental before you attend
the dentist.  For more details visit www.vhi.ie/dental

IMPORTANT
your policy number  must be included,
the tooth numbers must be entered where applicable and the dentist must be identified by his/her IDC/GDC number  on the claim form

If you have questions  about  your claim, call our DENTAL CLAIMS HELPLINE on 046 9077 337 from 8:30am  - 6pm, Monday to Friday,
9am - 2pm, Saturday. Our experienced  staff
will be happy to help.

CLAIM CHECK LIST

Please  ensure you have: Filled in and signed section A Entered your bank details
Your dentist has filled in section B with relevant costs
Attached  all receipts
Section C is complete  with dentist IDC/GDC number
The dentist has stamped and signed the form

CLAIMS ADMINISTRATOR
Vhi dental Claims, Aria Insurance Services  Limited, IDA Business Park, Navan,  Co. Meath
Phone: 046 90 77337
email: vhidentalclaims@aria-assistance.com

SECTION A  Insured detaIls: to be fIlled In by member

Name of policyholder		
Name of member	[patient.title] [patient.firstname] [patient.lastname]	
Policy number		Member date of birth	[patient.dob]	

Payment to	Dentist     ¨ If dentist,  bank details are not required on this form
Member   ¨ If member,  please enter bank details below	
Total claimed	€	
IBAN																																			
BIC													
Member address	[patient.address1], [patient.address2], [patient.address3], [patient.address4]	
Email	[patient.emailaddress]	Do you wish to receive settlement details by email?	
Yes ¨ No ¨	
Contact  numbers	Home [patient.homephone]	Mobile [patient.mobilephone]	
Was this treatment received as a result  of an emergency abroad  or following an accident?
If yes, please provide full details on a separate sheet.	
Yes ¨ No ¨	
does the claimant  hold dental insurance or any form of dental or medical  insurance with  any other  provider? If yes,  please provide details below:	
Provider:		Policy number:		

CUSTOMER DECLARATION
I confirm that  the facts stated  on this form are true, accurate  and correct to the best of my knowledge. I give authority to
the insurers or their representatives to contact  my dental practitioners  for full details of my dental or medical records and any additional information  required in connection with this claim. I understand that  the information  provided in relation to this claim may be shared with other insurers for the purposes  of eliminating insurance fraud. I further authorise  Aria Assistance to disclose all records they hold in relation to my policy, and any claim made or assistance provided under my policy, to the Voluntary Health Insurance Board of Vhi House, Lower Abbey Street, Dublin 1. I understand that  such records may include confidential medical information  or other material of a sensitive nature.

I/We hereby grant Aria Insurance Services Ltd. full rights to recover compensation from a liable third party any payments  made on My/Our behalf. I/We further agree to fully co-operate with any such recovery efforts from a liable third party or parties.	

DATA PROTECTION AND CONSENT:
The personal data and sensitive personal data that  you provide to the Vhi Group (“Vhi”) in this Claim Form, or which you authorise  third parties to provide, will be used within the Vhi group of companies  and by the insurer and their representatives for claims processing,  claims auditing (including clinical and billing audits), policy administration  and customer  care purposes. Data may also be used for statistical analyses and the detection and prevention  of fraud. We may share your data with trusted  third
parties who process data or conduct  clinical and/or billing audits on our behalf, inside and outside of the European Economic Area. We may also share your data with other insurers to verify your cover, and with state bodies as required by law. Clinical audit is a clinically led quality improvement process that  seeks to improve patient  care and outcomes through the systematic review of care against  explicit criteria and to act to improve care when standards are not met.

I confirm that  I give explicit consent  to my data,  including up to date medical diagnoses  information,  being held, used and processed  for the purposes  described above, including the purpose  of undertaking investigations  into, and to adjudicate  on, my claim (including the length  of my hospital stay and the treatment I received) and for the purposes  of Vhi providing me information about  products  and services aimed at managing my health and wellbeing.

You have the right, subject to certain exemptions,  to access any personal data that  we hold about  you (for which we may charge you a small fee) and to have inaccuracies corrected.  If you wish to avail of these  rights, please write to the Data Protection Office, Vhi House, 20 Lower Abbey Street, Dublin 1.

Vhi’s Data Protection Statement contains a further detailed  breakdown of the personal data we collect in relation to our customers and how we use that  personal data.  The Data Protection Statement can be found at www.vhi.ie or should you wish to contact  us on 1890 44 44 44, you can request  a hard copy.	

DECLARATION:
I declare that  the information  completed above at the time of signing this declaration  is true in every respect.  I authorise  the consultant/treatment facility concerned to supply all necessary information  to Vhi or its duly authorised agents  acting on its behalf including, if requested, copies of my hospital/medical  records in relation to this claim regarding  treatment or services received by me.

I also authorise  Vhi to pay the appropriate benefits  for services provided to the treatment facility and consultants concerned. I understand that  details of these  amounts will be included in my Vhi statement of payment,  and I will contact  Vhi directly with any queries. Charges which are not eligible for benefit  will remain my responsibility to settle directly with the consultant/treatment facility concerned.	

Policy Holder’s/Member’s Signature		
date		

SECTION B  ClaIm detaIls: to be fIlled In by a dentIst or authorIsed member of the practice

INVESTIGATION AND PREVENTATIVE TREATMENTS	
Code	Treatment	Qty	Treatment date	€ Fee	
120	Examination				
150	Extensive examination				
180	Periodontal examination				
230	X-rays small (each)				
272	X-rays bitewing series				
330	X-rays panoramic  or complete  series				
240	X-rays occlusal				
1110	Scale & polish				

EMERGENCY TREATMENT (OUT OF HOURS)		
Code	Treatment	Tooth no. required	Treatment date	€ Fee	
9110	Treatment of dental pain				
2940	Protective restoration				
9630	Prescriptions				

BASIC TREATMENTS: FILLINGS & SEALANTS             Surface required  for fillings

Code      Treatment                                                                  Tooth no. required        Treatment date                      € Fee

1351      Fissure sealant

2140

2150

2160

2161

2391

2392

2393

2394

Silver filling

White filling

BASIC TREATMENTS: PERIODONTAL	Tooth no. required	Treatment date	€ Fee	
4341	Perio scaling				
4910	Perio maintenance				
4355	Full mouth  debridement				
BASIC	Tooth no. required	Treatment date	€ Fee	
7140	Tooth extraction (general practice)				
7210	Surgical extraction (specialist)				
BASIC	Tooth no. required	Treatment date	€ Fee	
2930	Stainless steel crown				
MAJOR	Tooth no. required	Treatment date	€ Fee	
DO25	Onlay				
DI26	Inlay				
2752	Porcelain crown				
2952	Post & core				
2920	Recement crown				
2980	Repair crown				
2962	Porcelain veneer				
2960	Composite  veneer				

SECTION B  ClaIm detaIls: [CONTINUED]

MAJOR TREATMENTS: BRIDGES & IMPLANT CROWNS	Tooth no. required	Treatment date	€ Fee	
6242	Pontics				
6752	Bridge retainer				
6058	Implant crown				
MAJOR	Tooth no. required	Treatment date	€ Fee	
3310	Root canal canine or incisor				
3320	Root canal premolar				
3330	Root canal molar				
3220	Pulpotomy				
MAJOR	date	€	Tooth no. required	(TN)	date	€	
5110	Full upper			5213	Chrome P/-				
5120	Full lower			5214	Chrome -/P				
D57R	Reline			5211	Acrylic P/-				
D56R	Repair			5212	Acrylic -/P				
5650	Adjustment								
IMPLANT	Tooth no. required	Treatment date	€ Fee	
6010	Dental implant				
ORTHO	date treatment commenced	estimate treatment length in months (IOTN)	€	
8030	Limited ortho treatment				
8060	Interceptive ortho treatment				
8080	Comprehensive treatment child up to 18				
8090	Comprehensive treatment adult (IOTN Needed)				
Space Maintainers	Date appliance fitted	Missing  tooth number(s)	€	
D1505					
Miscellaneous items
List all other treatment not listed above		
TOTAL VALUE OF CLAIM

SECTION C dentIst detaIls: to be signed by a dentIst
I confirm that  the above patient  has received the treatment detailed above.

DENTIST DETAILS AND STAMP		

PRACTICE STAMP	
IDC/GDC number	[provider.gdcnumber]			
Name	[provider.name]			
Signature				
Practice phone  number	[practice.phone]			
Vhi dental network  number				

The Voluntary Health Insurance Board trading as Vhi Healthcare is regulated as an intermediary by the Central Bank of Ireland. Vhi Healthcare is tied to Aria Insurance Services Limited for Vhi Dental Insurance. This policy is underwritten by Great Lakes Reinsurance (UK) PLC.

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