Who Can Request an Appeal?
Parties to the initial determination can request an appeal including:
- Network dentists (only if appointed in writing by an appealable party to act on their behalf)
- The patient who received dental services
- Sponsors, parents, or guardians of beneficiaries who are under age 18 or mentally incompetent
- An individual or non-network dentist who has been appointed, in writing, by the patient to act as the patient’s representative in the appeal
The Appointment of Individual to Act as Appeal Representative Form can be submitted online or downloaded from the “Forms and Materials” section at www.uccitdp.com.
Who Cannot Request an Appeal?
The following cannot request an appeal:
- Dentists who are disqualified or excluded from being authorized dentists
- Non-network dentists (unless appointed in writing by an appealable party to act on their behalf)
- Beneficiaries who have an interest in receiving care or who have received care from a particular dentist who has been excluded, suspended, or terminated as an authorized dentist
- Sponsors, parents, or guardians of family members age 18 and older are not parties to the initial determination. However, they may represent the family member if the family member appoints them in writing
- Third parties such as other insurance companies
What Can and Cannot Be Appealed?
To appeal a claim, there must be a dollar 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 involved in the dispute were determined to be payable, minus any applicable cost-share or other dental insurance payment. Adverse decisions on predetermination requests may also be appealed.
The following issues cannot be appealed:
- Disputes regarding requirement of law or regulation
- The amount United Concordia determines to be the allowable charge
- Plan eligibility rules
- Dentists who have been excluded or suspended by a government agency or state or local licensing authority
- Amounts exceeding the patient’s plan year or lifetime maximum
- Services that are denied due to timely filing limitation