** 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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Glossary

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z
A
Abuse Any practice that is inconsistent with accepted sound fiscal, business, or professional practice which results in, unnecessary cost, or payment for procedures or supplies that are: (1) not within the concepts of necessary an appropriate care, or (2) that fail to meet professional recognized standards for health care providers. The term includes deception or misrepresentation by a dentist, or any person or entity acting on behalf of a dentist in relation to dental procedures reimbursement.
Active Duty Full-time duty in the Uniformed Services of the United States. It includes duty on the active list, full-time training duty, annual training duty and attendance while in the active Military Service, at a school designated as a Service school by law or by the Secretary of the Military Department concerned.
Active Duty Service Member (ADSM) A person on active duty in a Uniformed Service who is under a call or order that does not specify a period of 30 days or less. This contract only applies to the following Uniformed Services: The Army, Navy, Air Force, Marine Corps, and Coast Guard.
ADDP Patient Data Tracker United Concordia's on-line access to member information for dentists. It is available through Internet access or through the use of United Concordia's free software product.
Adjudication Claim processing procedures to determine benefits.
Adjunctive Dental Care Dental care which is medically necessary in the treatment of an otherwise covered medical (not dental) condition, is an integral part of the treatment of such medical condition and is essential to the control of the primary medical condition; or is required in preparation for or as the result of dental trauma which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).
American Dental Association (ADA) The ADA is the professional association of dentists committed to the public's oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards.
Amount in Dispute The amount of money, determined under this part, that the contractor would pay for medical procedures and supplies involved in an adverse determination being appealed if the appeal were resolved in favor of the appealing party.
Anesthesia Procedures The administration of an anesthetic agent injection or inhalation, the purpose and effect of which is to produce surgical anesthesia characterized by muscular relaxation, loss of sensation, or loss of consciousness when administered by or under the direction of a physician or dentist in connection with otherwise covered surgery. Anesthesia procedures do not include hypnosis or acupuncture.
Appeals/Reviews Procedures provided for enrolled members and participating dentists who disagree with United Concordia's claim decisions.
Appointment Control Number A number generated by United Concordia that is required by all ADSMs before receiving civilian care.
Assignment of Benefits Method by which payment for covered procedures is made to a non-participating dentist. If no assignment of benefits is made by the patient, payment will be made to the member for procedures provided by non-participating dentists. This benefit varies by state and by contract.
Authorized Dentist A licensed dentist (DDS or DMD), dental hygienist, CRNA or anesthesiologist who provides procedures within the scope of his/her license or registration, and who has not been excluded or suspended from providing service by their state licensing authority.
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B
Balancing Billing A dentist seeking any payment from a member for covered procedures for any amount in excess of the applicable allowable charge or for procedures outside of the authorization unless the ADSM agrees to pay prior to procedures being rendered.
Beneficiary Counseling and Assistance Coordinators (BCAC) BCAC is a Congressionally mandated initiative, implemented by the Defense Health Agency (DHA) to improve customer service, satisfaction, enhance beneficiary education and help reduce the volume of Congressional inquiries from beneficiaries. The FY2000 National Defense Authorization Act mandated the establishment of Beneficiary Counseling and Assistance Coordinator positions, full time at TRICARE Regional Offices and collaterally at Military Treatment Facilities world-wide. BCAC's act as a preventive mechanism for trouble-shooting TRICARE and Military Health System issues and concerns. A directory of BCAC locations may be found on the TMA website.
Benefits Dental procedures received by members for which all or part of the cost is authorized and paid for by United Concordia.
Billing Service An administrative service that a dentist may utilize to handle claim submissions, whether paper or electronic.
By-Report Procedures Procedures that require written justification/documentation from the treating dentist to be considered for coverage.
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C
Claim Request for payment for procedures rendered.
Claim Form Document that may be used as a claim for payment.
Confirmation Report An on-line report that is available for retrieval from United Concordia via a modem. The report gives confirmation that United Concordia has or has not received the file of claims that were electronically transmitted.
Consultation A deliberation with a specialist physician or dentist requested by the attending physician primarily responsible for the medical care of the patient, with respect to the diagnosis or treatment in any particular case. A consulting physician or dentist may perform a limited examination of a given system or one requiring a complete diagnostic history and examination. To qualify as a consultation, a written report to the attending physician of the findings of the consultant is required.
Consulting Physician or Dentist A physician or dentist, other than the attending physician or dentist, who performs a consultation.
Contract The award document that is a mutually binding legal relationship obligating the seller to furnish the supplies or procedures and the buyer to pay for them. This term normally represents the binding agreement between the Government and a private commercial, or public organization; however, for the purposes of this public/private competition solicitation, this term is also to be considered as encompassing the definition of the Letter of Obligation (LOO).
Contracting Officer A Government employee having authority to execute, administer and terminate contracts, and orders, and modifications thereto, which obligate Government funds and commit the Government to contractual terms and conditions.
Coordination of Benefits A system to determine who is primary payer and who is secondary payer when more than one health and/or dental insurance coverage applies to a dental procedure. (For the Active Duty Dental Program, TRICARE is always the primary payer).
Cost-share The amount of money for which the beneficiary is responsible in connection with otherwise covered dental procedures (other than disallowed amounts). A cost-share may also be referred to as a "copayment." (Does not apply to ADSM's.)
Covered Benefit Dental procedure included in a dental benefit plan subject to plan limitations.
Covered Procedures Dental procedure codes specified in a dental benefits plan.
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D
Date of Service For purpose of determining coverage, the date a service is completed (e.g., cementation date for a crown or bridge; insertion date of dentures; date root canal is sealed).
Defense Enrollment Eligibility Reporting System (DEERS) An automated system maintained by the Department of Defense for the purpose of maintaining personnel and benefit information for all Active Duty and Reserve service members and their family members. This information includes: address, contact information, military status, family status, births, adoptions, death, and divorce records.
Definitive Service A definitive service is any dental service other than a diagnostic service.
Denied Benefit Dental procedure denied based on a member's dental plan limitations.
Denied Service Dental procedure not covered by a dental benefits plan.
Dental Care Procedures relating to the teeth and their supporting structures.
Dental Encounter Data Dental Encounter Data records provide detailed dental information for each treatment encounter and are required to be produced by the contractor for dental care data and financial reporting.
Dental Readiness Classifications The oral health status of uniformed personnel are classified into four categories.
  • Class 1: Patients with current dental examination who do not require dental treatment or reevaluation. Class1 patients are worldwide deployable.
  • Class 2: Patients with current dental examination whose oral conditions are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable.
  • Class 3: Patients who require urgent or emergent dental treatment. Class 2 patients normally are not considered to be worldwide deployable.
  • Class 4: Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable. (NOTE: Class 4 is not used in this contract for reporting on the Dental Encounter Data records.)
Dental Service Point of Contact A military dentist assigned as the point of contract for all dental issues arising from care rendered to ADSM's in the civilian community and who review dental care for appropriateness. The DSPOCs for the members of the Army, Air Force, Navy, Marine Corps, and the Coast Guard will be located remotely from the contractor. The two DSPOC positions will rotate among the Army, Air Force, Navy and Coast Guard Dental Corps. The DSPOC positions are established to provide a means to identify, manage, and provide dental oversight of civilian dental care provided to ADSM's.
Dental Treatment Facility (DTF) A facility operated by the military that provides dental care to ADSM's. DTFs have responsibility for management of all service members within their service areas even if that service member is not in the same branch of service as the DTF base post. DTFs also manage the care of non-active duty service members (e.g, Reservists) who have a dental line of duty (LOD) determination while in a drill or on active duty for less than 30 days.
Dentist Doctor of Medicine (D.M.D) or Doctor of Dental Surgery (D.D.S.) who is licensed to practice dentistry by an appropriate authority.
DEOB Dental Explanation of Benefits. Computer-generated notice mailed to members and dentists explaining benefit determinations, i.e., type of service received, the allowable charge, the amount billed, cost share amount, etc. If a service is not paid, the DEOB also explains why payment was not allowed and how to appeal that decision.
Diagnostic Procedures Category of dental procedures including clinical oral examinations, radiographic examinations, and diagnostic laboratory tests and examinations provided in connection with other dental procedures authorized as benefits.
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E
Early Activators Some members of the National Guard and Reserve who are issued delayed-effective-date active duty orders for more than 30 days in support of a contingency operation, are eligible for "early" TRICARE medical and dental benefits beginning on either: (a) the date their orders were issued or (b) up to 180 days before they report to active duty. These members are eligible for the same dental procedures provided to active duty service members. National Guard and Reserve members assigned to military bases receive dental care through their local military dental treatment facility DTF. They are eligible to be referred for civilian dental care from their DTF.
Electronic Claims Submission (ECS) The process of transmitting insurance claims electronically from an office, billing service or clearinghouse to an insurance company.
Electronic Data Interchange (EDI) The electronic transmission of strategically important business data in a standard syntax by means of computer-to-computer exchange via a standard on-line transmission method.
Eligibility The rules set forth by the contract holder to determine which members may be enrolled in the dental program.
Emergency Care Emergency care (palliative care), which does not need authorization, includes any treatment necessary to relieve pain, treat infection, control hemorrhaging, or repair broken fillings by placement of a temporary or permanent fillings (not crowns). Root canal treatment may be needed to relieve the pain and infection. Crowns, bridges and dentures work is not considered emergency care.
Endodontic Procedures Procedures relating to the treatment of diseases of the dental pulp, pulp chamber and root canals.
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F
Facsimile (Fax) A device for transmitting copies of documents by wire or radio; also, a document transmitted by fax.
Fraud Fraud is defined as (1) a deception or misrepresentation by a dentist, beneficiary, sponsor, or any person acting on behalf of a dentist, sponsor, or beneficiary with the knowledge (or who had reason to know or should have known) that the deception or misrepresentation could result in some unauthorized benefit to self or some other person, or some unauthorized payment, or (2) a reimbursement for dental procedures that is false or fictitious, or includes or is supported by any written statement which asserts a material fact which is false or fictitious, or includes or is supported by any written statement that (a) omits a material fact and (b) is false or fictitious as a result of such omission and (c) is a statement in which the person making, presenting, or submitting such statement has a duty to include such material fact. It is presumed that, if a deception or misrepresentation is established and a request for reimbursement for dental procedures is filed, the person responsible for requesting reimbursement had the requisite knowledge. This presumption is refutable only by substantial evidence. It is further presumed that the dentist of the procedures is responsible for the action of all individuals who request reimbursement on behalf of the dentist (for example, billing clerks); this presumption may only be rebutted by clear and convincing evidence.
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G
Grievance A written complaint on a non-appealable issue which deals primarily with a perceived failure of a network dentist, or Contractor or subcontractor, to furnish the level or quality of care expected by an enrollee.
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H
HIPAA (Health Insurance Portability and Accountability Act) Federal Legislation that defines standard formats for health insurance transactions.
I
In-Progress Orthodontic Treatment Orthodontic treatment that began prior to the patient's enrollment in the ADDP.
Integral Procedures Procedures that are performed in conjunction with another service that dentists would not normally itemize with a separate charge.
Interactive Voice Response (IVR) system An automated system used to provide enrollment, procedure history, annual maximum, claim status, and benefit information. The dental office uses a touch-tone telephone to enter the request and the response can be provided via telephone, fax machine and/or mailed.
Internet Any large network made up of several smaller networks. Capitalized, the international network of the networks that connects educational, scientific and commercial institutions.
   
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L
Line of Duty (LOD) Reserve Component members, to include the National Guard members, serving on duty 30 days or less are not eligible for DTF dental care except for emergencies. The responsibility for determining eligibility for treatment rests with local commanders in accordance with published service regulations. The care may be received after a members is inactivated provided that the appropriate LOD documentation is on file; DEERS will not indicate eligibility.
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M
Medical The generally term which pertains to the diagnosis and treatment of illness, injury, pregnancy, and mental disorders by trained and licensed or certified health professionals. For purposes of the ADDP, the term "medical" should be understood to include 'medical, psychological, surgical, and obsterical,' unless it is specifically stated that a more restrictive meaning is intended.
Member Liability The ADSM has no legal obligation to pay for the costs of dental care or treatment received for covered services and, where required, services that were authorized. Member liability does include any expenses for procedures and supplies not covered but for which the member has agreed in writing to pay.
Military Medical Support Office (MMSO) The Military Medical Support Office was established to serve as the centralized Tri-Service point of contact for customer service medical/dental case management; to coordinate civilian health care procedures outside of the cognizance of a Military Treatment Facility for TRICARE Prime Remote (TPR) eligible Active Duty military and Reserve component service members within the 50 United States and District of Columbia.
Modem (Modulator-Demodulator) A device to connect a user's computer to communicate across standard telephone lines with other computers at different locations.
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N
Non-participating Dentist A dentist who has not signed a participating agreement with United Concordia.
National Practitioner Identifier (NPI) An identification number that is a government mandated requirement for electronic health care transactions and on paper claims in some states.
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O
Oral Surgery Procedures relating to the treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial region.
Orthodontic Procedures Procedures relating to the treatment of teeth in relation to the functions of occlusion and speech.
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P
Periodontal Procedures Procedures relating to the treatment of diseases of the supporting and surrounding tissues of the teeth.
Periodontics The examination, diagnosis, and treatment of diseases affecting the supporting structures of the teeth.
Priority Correspondence Correspondence, both hard copy and electronic, received by the contractor from the Office of the Assistance Secretary of Defense (Health Affairs), TMA, Surgeons General of the Military Services, Members of Congress, President of the United States, and any other correspondence designed as priority by TMA or the contractor's management.
Prevailing Charge The charges submitted by certain dentists which fall within the range of charges that are most frequently used in a state for a particular procedure or service. The top of the range establishes the maximum amount TRICARE will authorize for payments of a given procedure or service, except where unusual circumstances or dental complications warrant and additional charge.
Preventive Procedures Traditional prophylaxis including scaling deposits from teeth, polishing teeth, and topical application of fluoride to teeth.
Procedure Codes Codes used to identify and define specific dental procedures.
Prosthodontic Procedures Professional placement or maintenance of artificial teeth, either fixed or removable.
Provider Check Information Instant, secure access to view check summary, check detail and check related claims for a selected date range online.
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R
Referral ADSMs must receive a referral from a military DTF before receiving private sector dental care. The ADSM may not receive additional services not included in the referral unless a modified referral is provided by the DTF.
Restorative Procedures Restoration of teeth including those procedures commonly described as amalgam restorations, resin restorations, pin retention, and stainless steel crowns for primary teeth.
Routine Care Covered benefits for remote ADSM's that do not require TMA authorization which includes diagnostic (exams and X-rays), preventive (cleanings), routines restorations (amalgam or composite fillings), and single tooth extractions that does not exceed $750 per appointment. Does not include crowns.
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S
Sealants A material designed for application on specified teeth to seal the surface irregularities to prevent ingress of oral fluids, food and debris in order to prevent tooth decay.
Service Point of Contact (SPOC) Serves as a centralized service point of contact and is the primary POC for respective service headquarters and commands. Review dental reimbursement for eligibility and appropriateness of care. Refer fitness for futy issues to the member's unit and/or MTF. Provides pre-authorization for dental care procedures over $750 or cumulative total over 12 months that exceeds $1,500.00 for active duty members in remote locations.
Single Procedure Each dental procedure with a separate assigned procedure code.
Software A computer program or set of programs held in some storage medium and loaded into read/write memory (RAM) for execution.
Software Vendor A business that programs electronic claims submission software and then sells the software to dentists.
Specialty Care Other dental care (prosthodontics, periodontics, oral surgery) not considered emergency or routine care and requires either a referral from a DTF or an authorization from the DSPOC's.
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T
TRICARE Beneficiary An individual who has been determined to be eligible for TRICARE benefits, as set forth in 32 CFR 199.3
TRICARE Program A DoD managed health care program operated under the authority of 32 CFR 199.17.
TRICARE Regulation at 32 CFR Part 199 This regulation prescribes guidelines and policies for the administration of the TRICARE Program for the Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned Corps of the U.S. Public Health Service (USPHS) and the Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA). It includes the guidelines and policies for the administration of the TRICARE Program.
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U
Uniformed Services The Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned Corps of the USPHS, and the Commissioned Corps of the NOAA.
United Concordia United Concordia Companies, Inc., a subsidiary of Highmark, Inc., headquartered in Harrisburg, PA with support offices in Birmingham, AL; Phoenix, AZ; Woodland Hills, CA; Fresno, CA; Tampa, FL; Jacksonville, FL; Alpharetta, GA; Chicago, IL; Towson, MD; Troy, MI; Chesterfield, MO; Omaha, NE; Albuquerque, NM; New York, NY; Plainview, NY; King of Prussia/Philadelphia, PA; Pittsburgh, PA; Williamsport, PA; Dallas, TX; Houston, TX; San Antonio, TX; Glen Allen, VA; and Seattle, WA.
Utilization Management A set of techniques used to manage dental costs by influencing patient care decision-making through case-by-case assessment of the appropriateness and necessity of care either prior to, during, or after provision care. Utilization management also includes the systematic evaluation of individual and group utilization patterns to determine the effectiveness of the employed utilization management system designed to address aberrances identified through the evaluation.
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W
Windows® A software operating system developed by Microsoft.
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