Bento Dental Bill Upload

1

Is this the first time you are submitting a claim for services received at this dental office?

YESNO

2

Is your dental office in network with Bento?

YESNO

3

Is your dentist office aware that you have a dental plan that uses Bento?

YESNO

4

Tax ID of Dentist Office* This field is required.Please enter in the tax ID of your dentist office. This should be on your statement, bill, or claim form provided by your dentists. If one is not listed, please call your dentist office for that information or ask them to send an ADA claim form to Bento.

5

Patient Name:* This field is required.Name of patient.

First Name

Last Name

6

Dentist/Provider Name* This field is required.Name of the dentist/provide the patient saw

First Name

Last Name

7

Email* This field is required.Please provide an email so Bento can provide a status of your submission.

example@example.com

8

Date of Service* This field is required.

Date

9

Bento Member ID* This field is required.Please enter the Bento Member ID of the patient

Please include both letters and numbers

10

Out-of-Pocket Amount ($)* This field is required.

11

Upload Receipt* This field is required.Please upload your receipt/statement. Name of member and date of transaction must be visible. Services codes, provider Tax ID, NPI, and license should be included. If not, please also upload a completed ADA claim form.

Drag and drop files here

Select files to upload

12

Upload ADA Claim Form If your receipt does not contain all required information, please upload the completed ADA claim form provided by your dentist.

Drag and drop files here

Select files to upload

13

Please reach out to your dentist and provide them with your dental plan details before submitting your reimbursement to Bento.

Most dentist offices will submit claims on your behalf to your dental plan if they are aware of your benefits.

Please call your dentists, provide them with your member ID, our support number (800-734-8484), and ask them if they are able to submit the claim to Bento.

When they call us, we'll provide them with instructions for submitting a claim and confirm your plan details.

If you submit a reimbursement without notifying your dental office that your have a dental benefit, Bento may not be able to process the reimbursement.

14

Name

First Name

Last Name