CONUS Claims - for services provided through April 30, 2012

United Concordia will accept claims filed on any standard dental claim form of the American Dental Association (ADA) or on the TRICARE Dental Program (TDP) Claim form. For your convenience, this form can be filled out online, printed and mailed to United Concordia. A separate claim form must be submitted for each enrollee receiving services.

Whether or not you file a TDP claim depends on the type of dentist - participating or nonparticipating - you are seeing for treatment.

Additionally, any part of the dentist's fee exceeding United Concordia's allowance is your responsibility.

Submitting a Claim
When submitting a claim to United Concordia, it is important that all of the appropriate information is provided. Failure to provide the necessary information will result in a claim payment being denied.

If you have to file your own claim(s), be sure to include the following information on your claim form:

• Date(s) of service
• Specific problem encountered
• Procedure Code(s)
• Specific tooth/teeth treated for each service performed
• Total charges
• A complete description of the service performed, including applicable tooth/ teeth numbers, if a procedure code is not provided

You'll also need to include a dentist's bill or statement of charges if the specific service(s) provided are not found on the claim form.

Deadline for Filing Claims
Claim forms should be submitted to United Concordia as soon as possible after the service, preferably within 60 days. Claims submitted more than 12 months after the month in which the service was provided will be denied. Prompt submission is especially important for claims involving an orthodontic treatment plan, because the banding date is used to determine timely filing.