DENTAL CLAIM FORM/FORMULIR KLAIM DENTAL

POLICY NUMBER/ NOMOR POLIS: ………………………………

IMPORTANT NOTES/CATATAN PENTING
1. This claim form is to be sent to/formulir klaim ini dikirimkan ke: PT. Inova Care Indonesia, Gedung Menara Jamsostek, Menara Utara Lantai 3, Jl. Gatot Subroto No. 38 Kav. 71-73,
Jakarta Selatan 12710
2. For listings of current In-Network Providers and other inquiries, you may contact our Customer Service Hotline/Untuk daftar provider jaringan dan pertanyaan lain, mohon hubungi
Customer Service Hotline : 0800-1-333-111, Monday to Friday/Senin-Jumat, 8:30 am to 5:30 pm or visit us at/atau kunjungi kami di www.inovacare.com

SECTION A: GENERAL INFORMATION

Name of Policy Holder/ Nama ID # /PASSPORT #/ NO. Telephone Number/ Nomor
Pemegang polis: ID/ PASPOR: Telepon:

Surname/Nama Belakang First Name/Nama Depan Middle Name/Nama Tengah Country Code / Prefix / Number
Name of Member/Insured (Nama Date of Birth/Tanggal Mobile Number/Nomor HP:
Peserta Yang diasuransikan): Lahir:

Month / Day / Year

Surname/Nama Belakang First Name/Nama Depan Middle Name/Nama Tengah
(Bulan/Hari/ Tahun) Country Code / Prefix / Number
Address/Alamat: Sex/Jenis Kelamin: Email Address/Alamat Email:
Postal  Male/ Laki-laki
Street Address/Alamat Jalan City/Kota Province / State/Provinsi Code/Kode Pos  Female/ Perempuan
SECTION B/BAGIAN B: ACCIDENT OR EMERGENCY INFORMATION (to be completed by the Member)/ INFORMASI KEDARURATAN ATAU KECELAKAAN (dilengkapi
oleh peserta)
Date & Time of Accident/ Tanggal & Waktu Kecelakaan:
Nature of Injury/ Cedera yang dialami:
[ ] Please check if the registered address for claims payment is the same as indicated in Section A above for Accident or Emerg ency. If different, please provide us with the correct address/
Mohon centang jika alamat yang terdaftar untuk pembayaran klaim sama dengan yang tertera pada Bagian A untuk kecelakaan atau kedaruratan. Jika berbeda, silakan memberikan alamat
yang benar kepada kami.
PLEASE ATTACHED A COPY OF THE PHYSICIAN REPORT OR MEDICAL CERTIFICATE ASSOCIATED WITH THE ACCIDENT OR EMERGENCY/MOHON LAMPIRKAN SALINAN LAPORAN DOKTER
ATAU SERTIFIKAT MEDIS YANG BERHUBUNGAN DENGAN KECELAKAAN DAN KEGAWATDARURATAN
SECTION C/BAGIAN C: ELECTIVE DENTAL TREATMENTS (to be completed by the Dentist)/PERAWATAN GIGI TERENCANA (dilengkapi oleh Dokter Gigi)
Are you a Inova Care Network Provider?/ Apakah Anda jaringan penyedia layanan Inova Care?  YES/YA  NO/TIDAK
What is the Patient’s chief complaint or symptom?/Apa keluhan atau gejala utama pasien?
When did the Patient first notice or experience this symptom?/Kapan pertama kali pasien mengalami atau merasakan gejala ini?
How long did the Patient experience the problem before their consultation?/Berapa lama pasien mengalami gejala ini sebelum berkonsultasi?
DIAGNOSE/ DIAGNOSA:
TABLE OF DENTAL TREATMENT DETAIL (use additional pages if necessary)/TABEL RINCIAN PERAWATAN GIGI
PROCEDURE No. of Surfaces
DATE/TANGGAL Tooth #/ Quadrant Surface/ Clinic Billed Covered Amount/
CODE/ KODE No. Gigi /Kuadran Permukaan /Jumlah Amount/ Tagihan Jumlah yang dijamin
PROSEDUR Permukaan Klinik

SECTION D/BAGIAN D: PROVIDER REMITTANCE DETAILS/ DETAIL PEMBAYARAN PROVIDER

❑ Please transfer claim reimbursement to (Please furnish a copy of the bank book details for reference)/Mohon mengirimkan pembayaran klaim ke (mohon memberikan salinan buku
rekening bank sebagai referensi:
Bank Name/Nama bank: Branch Location/Cabang: Swift Code:

Routing Number/Nomor Routing: Account Name/Nama Rekening: Account Number/Nomor Rekening:

Clinic Name / Payee Name (Nama Klinik): Clinic Address/Alamat Klinik: Telephone Number/Nomor Telepon:
Street Address City Province / State Country Code / Prefix / Number

Signature of Dentist/ Date (Tanda tangan drg/Tanggal) Name of Dentist/Nama Dokter Gigi Stamp of Clinic/Hospital (Stempel Klinik/Rumah Sakit)
SECTION E/BAGIAN E: MEMBER REMITTANCE DETAILS (Emergency / Accident or Out-of-Network)/DETAIL PEMBAYARAN PESERTA (Kegawatdaruratan/ Kecelakaan atau di luar jaringan
provider)
Payee Name/Nama Pembayar: Branch/Cabang: Swift Code:

Routing Number/Nomor Routing: Account Name/Nama Rekening: Account Number/Nomor Rekening:

Mailing Address/ Alamat email: Telephone Number/Nomor Telepon:

Street Address
City / Province/Postal Code Country Code / Prefix / Number

Signature of PH/Claimant/Date (Ttd Pemegang polis/ Tanggal) Name of Policy Holder/Claimant (Nama Pemegang polis)

By signing this claim form, I also consent to having my treating dentist or physician share information about my dental record as necessary to process this claim.
I also consent to share information as required to process this claim for any out-of-network or dental emergency / accident treatment/
Dengan menandatangani formulir klaim ini, Saya juga setuju jika dokter gigi atau dokter yang merawat saya memberikan catatan gigi sebagaimana diperlukan untuk proses klaim. Saya
juga setuju untuk berbagi informasi yang diperlukan untuk memproses klaim ini untuk setiap penyedia layanan di luar jaringan atau kedaruratan/ perawatan kecelakaan.
DC 2012
 CODE DESCRIPTION CODE DESCRIPTION

DIAGNOSTIC VISIT/EMERGENCY ENDODONTICS (continued)

□
C-D0120 Periodic Dental visit(oral evaluation done with annual preventive care) □ C-D3320 Root canal therapy, bicuspid tooth (x-ray included, excluding final restoration)

C-D0150 Comprehensive oral evaluation, diagnostic or problem focused □ C-D3330 Root canal therapy, molar (x-ray included, excluding final restoration) □

Emergency visit (palliative treatment to relieve uncontrollable pain, swelling or □ □

C-D9110 C-D3450 Root amputation, per root
bleeding)
RADIOLOGY/ DIAGNOSTIC IMAGING PROTHODONTICS

C-D0210 X-ray, intraoral complete series (including bitewings) □ C-D5110 Complete denture, maxillary □

C-D0250 X-ray, intraoral or bitewing- first film □ C-D5120 Complete denture, mandibular □

C-D026 X-ray, intraoral or bitewing- each additional film □ C-D5211 Maxillary partial denture, resin base (incl. conventional clasps, rests and teeth) □

C-D0290 Posterior-Anterior or lateral skull and facial bone survey film □ C-D5212 Mandibular part, denture, resin base □

□ Maxillary partial denture cast metal framework w/ resin denture bases (inc. clasps, □
C-D0330 Panoramic x-ray C-D5213
rests and teeth)
□ Mandibular partial denture cast metal framework w/ resin denture base (inc. clasps, □
C-D0350 Oral/ facial photographic images C-D5214 rests and teeth)
C-D0470 Diagnostic casts (dental model for diagnosis or a study model) □ C-D5650 Add tooth to existing partial denture □

PREVENTIVE CARE C-D5710 Rebase complete or partial maxillary denture □

C-D1110 Prophylaxis/scaling and cleaning adult □ C-D5711 Rebase complete or partial mandibular denture □

C-D1120 Prophylaxis/ cleaning-child □ C-D5730 Reline complete or partial maxillary denture □

C-D1203 Application of fluoride- adult □ C-D5731 Reline complete or partial mandibular denture □

□ □
C-D1204 Application of fluoride- child C-D6740 Fixed partial denture- crown in porcelain/ceramic

C-D1351 Sealant (per tooth) □ C-D6750 Fixed partial denture-crown porcelain fused to high noble metal □

RESTORATIVE C-D6751 Fixed partial denture-crown porcelain fused to predominantly based metal □

C-D2150 Amalgam, 1-2 surfaces, primary or permanent □ C-D6752 Fixed partial denture-crown porcelain fused to noble metal □

C-D2161 Amalgam, 3-5 surfaces, primary or permanent □ DENTAL IMPLANT SERVICES

C-D2331 Resin-based composite, 1-2 surfaces, anterior or posterior □ C-D6010 Surgical placement of implant body: endosteal implant (complete) □

C-D2335 Resin-based composite, 3-5 surfaces, anterior or posterior □ C-D6100 Implant removal, by report □

C-D2510 Metallic inlay, 1-2 surfaces □ C-D6053 Implant/abutment supported removable denture for completely edentulous arch □

C-D2530 Metallic inlay, 3 or more surfaces □ C-D6058 Abutment supported porcelain/ ceramic crown □

C-D2542 Metallic onlay, 2 surfaces □ C-D6059 Abutment supported porcelain fused to metal crown (high noble metal) □

C-D2544 Metallic onlay, 4 or more surfaces □ C-D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) □

C-D2620 Porcelain/ceramic inlay, 1-2 surfaces □ C-D6061 Abutment supported porcelain fused to metal crown (noble metal) □

C-D2630 Porcelain/ceramic inlay 3-5 surfaces □ C-D6062 Abutment supported cast metal crown (high noble metal) □

C-D2643 Porcelain/ceramic onlay, 2-3 surfaces □ C-D6063 Abutment supported cast metal crown (predominantly base metal) □

C-D2644 Porcelain/ceramic onlay, 4 or more surfaces □ C-D6064 Abutment supported cast metal crown (noble metal) □

□ Implant/abutment supported fixed denture for completely edentulous arch (Hybrid □

C-D2740 Crown, porcelain ceramic substrate C-D6078
Prosthesis)
□ Implant/abutment supported fixed denture for partially edentulous arch (Hybrid □
C-D2750 Crown/porcelain fused to high noble metal C-D6079
Prosthesis)
C-D2751 Crown, porcelain fused to predominantly base metal □ C-D6068 Abutment supported retainer/porcelain/ceramic crown FPD □

□ Abutment supported retainer/ porcelain fused to metal crown FPD (high noble □
C-D2752 Crown, porcelain fused to noble metal C-D6069
metal)
□ Abutment supported retainer/ porcelain fused to metal crown FPD (predominantly □
C-D2799 Provisional crown C-D6070 base metal)
C-D2920 Recement crown, inlay or onlay or partial coverage restoration □ C-D6071 Abutment supported retainer/ porcelain fused to metal crown FPD (noble metal) □

C-D2930 Prefabricated Stainless steel crown Primary or Permanent tooth □ C-D6072 Abutment supported retainer/ cast metal crown FPD ( high noble metal) □

C-D2940 Sedative or medicated filling □ □

C-D6073 Abutment supported retainer /cast metal crown FPD (predominantly base metal)

C-D2950 Core build up, including any pins □ C-D6074 Abutment supported retainer /cast metal crown FPD(noble metal) □

C-D2952 Post and Core in addiction to crown, indirectly fabricated □ C-D6092 Recement Implant/abutment supported crown or fixed partial denture □

C-D2954 Prefabricated Post and Core in addiction to crown □ ORAL AND MAXILLOFACIAL SURGERY-INCLUDING LOCAL ANESTHESIA & POSTOPERATIVE CARE

C-D2961 Labial veneer (resin laminate) □ C-D7140 Simple Extraction erupted tooth or exposed root □

C-D2962 Labial veneer (porcelain laminate) □ C-D7230 Complicated extraction, tooth or root, partially bony □

PERIODONTICS C-D7240 Surgical removal or impacted, completely bony tooth □

Gingivectomy or gingivoplasty 4 or more contiguous teeth or tooth bounded □ □

C-D4210 paces per quadrant C-D7250 Surgical removal of residual tooth roots
□ □
C-D4211 Gingivectomy or gingivoplasty, 1-3 contiguous teeth or tooth per quadrant C D7510 Incision and drainage of abscess intraoral soft tissue
□ □
C-D4240 Gingival flap procedure, including root planning, 4 or more teeth per quadrant C D7520 Incision and drainage of abscess extraoral soft tissue
Gingival flap procedure, including root planning 1-3 contiguous teeth per □ □
C-D4241 C D7610 Treatment of simple fracture, maxilla or mandible open or closed reduction
quadrant
□ □
C-D4245 Apically positioned flap C D7710 Treatment of compound fracture, maxilla or mandible open or closed reduction
□
C-D4263 Bone replacement graft (per quadrant) ORTHODONTICS
□ □
C-D4265 Biologic materials to aid in soft and osseous tissue regeneration C D8040 Limited orthodontic treatment x adolescent adult (excluding maintenance)
□ □
C-D4321 Provision splinting- extracoronal C D8090 Comprehensive orthodontic treatment x adolescent adult (including maintenance)
□ □
C-D4341 Scaling and root planning- 4 or more teeth per quadrant C D8210 Removable appliance therapy (Minor treatment to Control Harmful Habit)
□ □
C-D4342 Scaling and root planning- 1-3 teeth per quadrant C D8660 Pre orthodontic treatment visit (initial evaluation)
□
ENDODONTICS Periodic orthodontic treatment (in conjunction w/ orthodontic treatments, D8030 and
C D8670 D8040)
Therapeutic pulpotomy and application of medicament (excluding final □ □
C-D3220 restoration) C D9940 Fabrication of occlusal hard splint athletic mouthguard
□ □
C-D3310 Root Canal therapy, anterior tooth (x-ray included, excluding final restoration) C D9972 External bleaching or whitening (complete)

DC 2012