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TRICAREĀ® Dental Program
Dentists Government
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    • TRICARE Dental Program
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    • Readiness Form
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    • How to submit a claim
    • Submit a Claim
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Dentists Government

United Concordia is dedicated to helping our TDP enrollees throughout the country who have been impacted by a disasters. We realize you are wrestling with many issues and concerns in light of the current situation - your dental care shouldn’t be one of them. 

If your dental treatment has been impacted by a recent disaster, please contact United Concordia’s disaster line at 1-800-858-0051 to locate a dentist, coordinate benefits, and answer any questions regarding dental coverage. Please let us know you’ve been affected by the disasters when you call.

EDUCATIONAL MATERIALS

TRICARE Dental Handbook
This booklet provides detailed information regarding beneficiary TDP benefits and how to manage them.
Download
TDP Benefit Brochure
This brochure provides an overview of the TDP.
Download

FORMS

Please note: Only the claim form should be used to submit claims. Click here to submit a claim online via Speed eClaim.

Enrollment Form
As an alternative to using the online enrollment tool, this form can be used to enroll or cancel enrollment. Sponsors should review the instructions on page 2 for filling out the enrollment form.
Download
TDP Claims Form (CONUS)
This form is used to file a claim for services rendered in the Continental United States (CONUS). For convenience, it can be filled out online, printed and mailed to United Concordia.
Download
TDP Claims Form (OCONUS)
Use this form to file a claim for services rendered Outside of the Continental United States (OCONUS).
Download
NARF (Non Availability Referral - OCONUS Only)
A NARF is an OCONUS form used by Overseas Dental Treatment Facilities (ODTFs) and TRICARE Area Offices (TAOs) to refer enrolled members to local host country dentists for orthodontic services. For your convenience, this form can be filled out online, printed and mailed to United Concordia.
Download
Custodial Parent Release Form
This form should only be completed when a natural parent who is listed on a TDP contract is authorizing the other natural parent who is not listed on the TDP contract to receive information on their natural child under the age of 18.
Online Form Download
POA (Power of Attorney)
This form is used to submit Power of Attorney information in order to manage the TDP account on behalf of the sponsor.
Online Form Download
HIPAA Privacy Release Form
This form should be completed to release PHI 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 Regulations.
Online Form Download
Appointment of Individual to Act As Appeal Representative Form
This form will need to be completed by the patient/or parent of a child under the age of 18 when a non-participating provider is requesting a reconsideration on their patient's behalf.

This form will also need to be completed if a member would like to appoint an individual to appeal a claim on their behalf. The member must complete the Request and Authorization for Disclosure of Health Information 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.
Online Form Download
Appeals
A claim denial can be appealed by completing the Appeals Form. This form must be completed entirely and submitted to United Concordia before an appeal can be processed. In order to submit a formal review request, the provider must have the attached Appointment of Individual to Act As Appeal Representative form signed by the beneficiary. The signed form MUST be included in the formal review request.
Online Form
Grievance
If a beneficiary would like to submit a concern regarding a quality of care issue, he/she should complete the attached form and return it to United Concordia's Grievance Unit. Beneficiaries can complete it online or print the form and mail/fax to United Concordia.
Online Form
Fraud Complaint Form
If a beneficiary believes that a dentist or entity has received insurance money through the submission of a false claim, he/she should report this information to the Special Investigations Unit (SIU).
Online Form Download
DD Form 2813 (Guard Reserve - Dental Readiness Classification)
The DD Form 2813, DoD Active Duty/Reserve Forces Dental Examination, will be used to assist the TDP-enrolled National Guard/Reserve forces in documenting member dental health.
Download
Nominate My Dentist
If a beneficiary would like to nominate their dentist for participation with United Concordia, he/she should submit the Nominate My Dentist form.
Online Form
Contact Us (Customer Service form -OCONUS, CONUS)
Beneficiaries can use this form to submit a question to a United Concordia representative regarding the TDP or their benefits.
Online Form
 
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