** 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

Form Name: Description:
DTF Manual This manual is an ADDP reference guide for DTF staff. As program modifications are implemented, the manual will be updated to reflect the changes. Download it as a pdf or print a copy for your reference.
DTF Referral Sheet This referral sheet contains the most commonly used CDT codes and is for the military dentist's reference. It does not take the place of the Referral Request Form. Military dentists can use this form to select the procedures to be referred to a civilian provider. Administrative personnel can use this form to complete the Referral Request Form in DART.
DTF Orthodontic Referral Forms The DTF Orthodontic Referral Form and DTF Referral Request Form (both are included in the link at the left) must be completed by DTFs wishing to refer ADSMs for private sector orthodontic treatment. Both forms must be completed in their entirety and submitted to the appropriate branch of service contact as noted on the orthodontic referral form after the DTF receives the orthodontic treatment plan from the civilian provider. ADSMs may not receive orthodontic treatment until the request has been approved by the Government.
ADDP DTF-referred Flyer DTF staff distribute this flyer to ADSMs who have been referred for private sector dental care. It is provided here in PDF format for easy navigation.
ADDP Remote Brochure The ADDP Remote Brochure is mailed 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.
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.
Make Your Own Appointment Card ADSMs may consult this flyer for ADDP guidelines and processes for making their own appointment.
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.
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 the ADSM's dental explanation of benefits from United Concordia. If the ADSM does not have a DEOB, he/she can contact United Concordia at 1-866-984-ADDP (1-866-984-2337) to check the claim status and receive this information.
ADDP Grievance Form If you would like to submit a concern regarding a quality of care issue, complete the form and return it to United Concordia's Grievance Unit. You can submit the form online or print the form and mail/fax it to United Concordia.
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.
Material Order Form (Government only) Use this form to order hard copies of ADDP-specific forms and materials.
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.
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