If you or your participating dentist disagrees with United
Concordia's benefit decision, the decision in question
may be eligible for an appeal. During the appeals process,
those involved in the initial determination have the
opportunity to appeal adverse benefit decisions.
In order for a claim to be appealed, there must be an amount
in dispute for which the patient has financial responsibility.
The amount in dispute is calculated as the actual amount that
would be payable under the TRICARE Dental Program (TDP)
if the services in the dispute were determined to be payable,
less any applicable
cost-share or other dental insurance payment. You
may also appeal adverse decisions on
predetermination requests.
The following issues cannot be appealed:
Disputes regarding requirement of
law or regulation
The amount United Concordia
determines to be the allowable charge
Patient eligibility
Dentists who have been excluded
or suspended by a Government agency or state or local
licensing authority
Amounts exceeding the patient's
contract year or lifetime maximum
Services that are denied due to
timely filing limitation
Who Can Request an Appeal?
Parties to the initial determination can request an
appeal, including:
Participating dentists
The patient who received the
dental services
Sponsors, parents or guardians
of members younger than 18 years of age
Who Cannot Request an Appeal?
The following cannot request an appeal:
Dentists who are disqualified or
excluded from being authorized dentists
Nonparticipating dentists
(unless appointed in writing by an appealable
party to act on his or her behalf)
Members who have an interest in
receiving care or who have received care from a dentist
whose authorization has been excluded, suspended or
terminated
Sponsors, parents or guardians of
family members 18 years of age and older are not parties
to the initial determination. However, they may
represent the family member if appointed
- in writingnbsp;- by that
family member. Download the
Appointment of Individual to Act as Appeal
Representative Form, which can also be found in the
Forms/Materials section.
