** Notice for ADDP Members Impacted by Natural Disasters **

United Concordia is dedicated to helping ADDP members impacted by natural disasters. We realize you are wrestling with many issues and concerns in light of this tragedy - your dental care shouldn't be one of them.

If you have been displaced as a result of a natural disaster and your ADDP benefits and/or access to care have been affected, please contact us at 1-866-984-2337. We are committed to helping our enrollees affected by tragedy. Please do not hesitate to contact us so we can be of assistance.

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Forms & Materials

Remote ADDP Forms and Materials

Form Name: Description:
ACN Request Form This form is for Remote ADSMs who do not need authorization to receive private sector dental care. You must submit this form and receive an Appointment Control Number (ACN) from United Concordia before receiving private sector dental care. 
Command Memorandum - LOD dental care This memorandum is required for all LOD dental care. It must be signed by the unit and submitted with the ADDP claim form.
Command Memorandum - 
Implant Treatment
This memorandum is required for all dental implant authorizations. It must be signed by your unit and submitted by the network civilian dentist upon completion of the Authorization Request Form. Note: NOAA Corps members must have the Command Memorandum signed by the Commissioned Personnel Center.
Authorization to Appeal Remote ADSMs may appeal a claim denial by contacting United Concordia in writing. If you would like to authorize another individual to file a claim on your behalf (e.g., spouse or other family member), complete the Authorization to Appeal and submit it to United Concordia. You must complete the Request and Authorization for Disclosure of Health Information (HIPAA Release) 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.
ADDP Remote Brochure The ADDP Remote brochure is provided to all Remote ADSMs. This brochure explains the ADDP and how to receive private sector dental care. It is provided here in PDF format for easy navigation.

Other Forms and Materials
*Please note: Only the claim form should be used to submit claims

Form Name: Description:
Make Your Own Appointment Card ADSMs may consult this flyer for ADDP guidelines and processes for making their own appointment.
ADDP DTF-referred Flyer This flyer is provided to ADSMs who have been referred by their DTF to receive private sector dental care. It is provided here in PDF format for easy navigation.
Fast Facts This flyer provides basic facts about the ADDP and can be used by ADSMs and DTF staff as a quick reference guide and program overview.
Line of Duty Guidelines This flyer describes the process that ADSMs must follow in order to receive Line of Duty (LOD) dental care under the Active Duty Dental Program (ADDP). The LOD determination process for dental care is for those Reserve Component service members who incur or aggravate an injury, illness or disease while on active duty, and are not otherwise eligible for care under the ADDP.
DD Form 2813 Active Duty/Reserve Forces Dental Examination - The Government requires all Active Duty and Reserve members receive an annual dental examination. This form should be completed by the DTF or civilian provider and will be used to assist the Services in documenting member dental health.
ADDP Claim Form United Concordia's network dentists will file a claim on your behalf. If you are approved to utilize a non-network dentist, you may be required to submit your own claim form. For your convenience, this form can be downloaded from the ADDP Web site, printed and mailed to United Concordia.
Appeal Form ADSMs may appeal a claim denial by completing the Appeal Form. The form must be completed entirely and submitted to United Concordia before an appeal can be processed. All information required to submit this form can be found on your dental explanation of benefits you received from United Concordia. If you do not have your DEOB, you can contact United Concordia at 1-866-984-ADDP (1-866-984-2337) to check your claim status and receive this information.
Grievance Form If you would like to submit a concern regarding a quality of care issue, complete the attached form and return it to United Concordia's Grievance Unit. You can complete it online or print the form and mail/fax it to United Concordia.
HIPAA Release 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 Fraud Form If you believe a dentist or entity has received insurance money through the submission of a false claim, you should report this information to the Special Investigations Unit (SIU).

Download form for mailing.

*Please note: These forms should not be used to submit claims.
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