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.
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.
TDP Claims Form (OCONUS)
Use this form to file a claim for services rendered Outside of the Continental United States (OCONUS).
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.