Predeterminations and Supporting Documentation

Before treatment begins for services such as inlays, onlays, crowns, prosthetics, periodontics and oral surgery, you may file an ADA claim form with Kansas City Life Insurance Company. We will provide a written response indicating services that will and/or will not be covered per the plan guidelines.

Include the following:

• Procedure(s) using current ADA codes
• Billed Charges
• Dental Necessity
• Applicable supporting X-rays, extraction information, periodontal charting

To file a predetermination electronically go to the website below and register:

• Smart Data Solutions (SDS) 855-297-4436 or visit the website.
• When registering you will need our payer number, which is CX058

If you prefer to file the predetermination via mail, please send to:

• Kansas City Life Insurance Company
  P.O. Box 292
  Milwaukee, WI 53201-0292