TRICARE Active Duty Dental Program - United Concordia

File an Appeal


You, your designated representative or your dentist may submit an appeal of a denied claim or service. If you choose to submit the appeal, please note that information from your Dental Explanation of Benefits (DEOB) is required to complete the following form to begin the Appeal Process. If you do not have a DEOB, contact your dentist or contact Customer Service at 1-866-984-2337.
Relationship to Patient *I am the...
*Explanation of Appeal
Appeal Information
*Procedure Code
(D1234)
*Service Date
(mm/dd/yyyy)
*Provider's Charge
Tooth Number/
Range/
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Surfaces
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Patient Information
- OR -
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Attachments Please enter patient Social Security Number before uploading attachments. Once you have uploaded attachments, you will not be able to edit the SSN.
*I acknowledge and agree that by selecting this box I am electronically signing this document and intend for it to be my legal signature. I represent that all information in this document is correct to the best of my knowledge.