Active Duty Dental Program

Appeals

Appointment of Individual To Act as Appeal Representative form

Active duty service members in remote locations may appeal a claim denial by contacting United Concordia in writing.

Would you like to authorize another individual (spouse or other family member) to file a claim on your behalf?

You must complete and submit these forms to United Concordia before your appeal can process:

• Authorization to Appeal
• Authorization for Disclosure of Medical or Dental Information (HIPAA Release) form
• Appointment of Individual to Act as Appeal Representative Form

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 get civilian dental care. You must submit this form and receive an Appointment Control Number from United Concordia before you get civilian dental care.

Claims

United Concordia’s network dentists will file claims for you. Are you authorized to visit a non-network dentist? You may have to submit your own claims.

CONUS Service Area	OCONUS 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

Do believe a dentist or entity has received insurance money through the submission of a false claim? You should report this 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'd like to submit a concern regarding a quality of care issue, complete the form and send it to United Concordia’s Grievance 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

Complete this form 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.