Active Duty Dental Program

Appeals

Appointment of Individual To Act as Appeal Representative form

Active duty service members in remote locations may AppealThe action you take if you don’t agree with a decision made about your benefit. a claim denial by contacting United Concordia in writing. If you would like to authorize another individual to file a claim on your behalf (spouse or other family member), complete the Authorization to Appeal and submit it to United Concordia. You must complete the Authorization for Disclosure of Medical or Dental Information (HIPAA Release) form and the Appointment of Individual to Act as Appeal Representative Form. Both forms must be received and completed entirely before an appeal can be processed.

Appointment Requests

Request an Appointment Control Number online.

This form is for active duty service members in remote locations who don’t need authorization to receive private sector dental care. You must submit this form and receive an Appointment Control Number from United Concordia before you get private sector dental care.

Claims

United Concordia’s network dentists will file claims for you. But if you’re authorized to visit a non-network dentist, you may have to submit your own claims.

CONUS50 United States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands Service Area	OCONUSAreas outside of the 50 United States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands Service Area
Mail the claim form to: United Concordia Companies, Inc. ADDP Claims P.O. Box 69429 Harrisburg, PA 17106-9429	Mail the claim form to: United Concordia Companies, Inc. ADDP OCONUS Dental Unit P.O. Box 69457 Harrisburg, PA 17106-9452

Dental Readiness

Department of Defense Active Duty/Reserve/Guard/Civilian Forces Dental Examination (DD Form 2813)

This form is used to assist active duty and National Guard and Reserve members in documenting dental health for worldwide duty. Download the form and give it to your dental provider to complete. Due to security settings, you may have to right-click and choose “Save As” to download this form. You can also download the form directly from the WHS forms page.

Fraud

ADDP Fraud Complaint Form

If you believe a dentist or entity has received insurance money through the submission of a false claim, you should report this information to the Special Investigations Unit.

United Concordia Companies, Inc.
Special Investigations Unit
1800 Center St.
Camp Hill, PA 17089

Fax: 877-603-6091

Grievances

File a grievance online.

If you would like to submit a concern regarding a quality of care issue, complete the form and send it to United Concordia’s GrievanceYou can file a grievance when:
- You have a complaint about the quality of care you received,
- A provider or facility behaved inappropriately, or
- You have any other non-appealable issue.
The grievance may be against any member of your health care team. This includes your TRICARE doctor, your contractor, or a subcontractor. Unit.

United Concordia Companies, Inc.
ADDP Grievances
1800 Center St.
Camp Hill, PA 17089

Fax: 717-635-4560

Disclosure of Health Information

Authorization for Disclosure of Medical or Dental Information form

This form should be completed to release protected health information between spouses, for children 18 years and older, or any other person not authorized to receive information without written authorization. This is necessary due to HIPAA Privacy Rule regulations.