Dentist'S Claim Form (Page 2 of 2) in pdf

Completing the TDP Claim Form

AGENCY DISCLOSURE STATEMENT - The public reporting burden for this collection of information is estimated to average

15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this

burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the

Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management

Division. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any

penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.

The completed form should be sent to United Concordia, TDP CONUS Dental Unit, P.O. Box 69411, Harrisburg, PA 17106-9411

Most of the TDP Claim Form is self-explanatory; however, there are certain fields to which special attention should be paid:

• Upper left corner. Dentist’s Claim Form: Check the appropriate box to indicate if your claim is for predetermination

(estimate of services to be performed) or for services actually received.

• Box 2. Relationship to sponsor: For example, self, spouse, or child.

• Box 7. Sponsor’s Social Security number (SSN): The sponsor’s nine-digit SSN must appear on every claim form.

• Box 8. Patient mailing address: Be sure to provide the current and complete mailing address to include APO/FPO

and/or street, city, state, country, and postal mailing code.

• Box 10. Release of Information

• Box 13. Is patient covered by another dental plan?: Check “No” if the family member has no other dental insurance.

If the family member has additional dental insurance, please check “Yes” and include the plan name, insured name and

Social Security number, group number, and address of the other carrier.

• Box 14. Assignment of Benefits: Sign if the family member, parent, or guardian wants to assign payment of benefits to

the dentist; if signed, United Concordia will send payment to the dentist directly.

• Box 15. Dentist name; 15a. Provider no.: The provider number represents the provider number assigned by United

Concordia.

• Box 16. Mailing address: Include street, city, state, country, and postal mailing code.

• Box 30. Examination and treatment plan: Provide a detailed description of the services performed, including applicable

tooth numbers, dates of service, and the fee charged.

General Instructions

• Submit a separate claim form for each family member who receives treatment.

• All claim forms should be submitted to United Concordia as soon as possible after the service date, preferably

within 60 days of the date of service. Claims postmarked more than 12 months after the date of service will be denied.

• The member must sign the appropriate sections of the claim form. If the family member is under 18 years of age, the

parent or guardian must sign the form.

• The dentist must sign the appropriate sections of the claim form.

Dentist'S Claim Form Page 2