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Appeals

Appeals

You are required to have an Appointment Control Number prior to accessing private sector dental care. If you do not receive one prior to receipt of care, your claim may be denied. You may appeal a claim denial by completing the online appeal form. The form must be completed in its entirety with information found on the ADSM’s dental explanation of benefits (DEOB). If you do not have the DEOB, you can contact United Concordia at 1-866-984-ADDP (1-866-984-2337) to check the claim status and receive this information.

You may also choose to submit an appeal in writing detailing why you are appealing denied charges, as well as a copy of the bill. Paper appeals should be sent to United Concordia at:

  • United Concordia Companies, Inc.
  • ADDP Unit - Appeals
  • P.O. Box 69430
  • Harrisburg, PA 17106-9430

There are three levels of appeal for the ADDP.

First Level. Any appeal of a claim denial must be submitted to United Concordia within 90 calendar days of the notice of the denial. United Concordia will forward the appeal to the dental service point of contact (DSPOC) who will issue a decision to United Concordia. United Concordia will then notify the ADSM (or the person initiating the appeal) of the DSPOC's decision. Please note: The appeal request must be submitted with the appropriate diagnostic materials. If the dental service to be appealed involves a prosthetic procedure (e.g., crown, bridges, etc.) that requires cementation, the appeal must also include a radiograph showing the completed prosthetic procedure. For a complete listing of diagnostic materials required, please view the Diagnostic Material Requirements.

Second Level. In the event the DSPOC denies the appeal, then the ADSM (or authorized representative) may request an additional review of the DSPOC's decision within 30 calendar days of receipt of the denial. In order to obtain further review of the DSPOC's decision, the ADSM (or authorized representative) must submit a request for review of the DSPOC's decision to United Concordia. The request for review must include a copy of the DSPOC's original decision. The DSPOC will review the appeal and issue a decision to United Concordia, either affirming or reversing the DSPOC's first level decision. The decision may overrule the previous decision in whole or in part.

Final Level. In the event that the DSPOC affirms the first-level decision, the ADSM (or authorized representative) may seek further review by submitting a request to United Concordia within 30 calendar days of receipt of the second decision. The request must include copies of the first and second level decisions. United Concordia will forward the request to the DSPOC for review by the Surgeon General or designee for the ADSM's Branch of Service, with a copy to the DHA Dental Care Branch. The Surgeon General or designee for the ADSM's Branch of Service decision is final and cannot be appealed.

 
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