United Concordia Claim Form

United Concordia Claim Form - 1 Type of Transaction Mark all applicable boxes Dental Claims FEDVIP P O Box 69416 Statement of Actual Services Request for Predetermination Preauthorization Harrisburg PA 17106 9416 EPSDT Title XIX 2 Predetermination Preauthorization Number POLICYHOLDER SUBSCRIBER INFORMATION For Insurance Company Named in 3 12

Electronic Claims Submitting claims electronically with our free online tool saves your dental office time and money and enables you to get paid faster TOPD users should use the service links on the TOPD Online Services page Speed eClaim FREE electronic claims submission to United Concordia Quicker processing means you get paid faster

United Concordia Claim Form

United Concordia Claim Form

Specialist Services requested: Reason for referral: This section must be completed for Prophylaxis date(s): Root planing/scaling /indicate quadrant and date(s): periodontal referrals Root planing or peri o maintenance follow-up date(s): SECTION 3 - APPOINTMENT INFORMATION/TO BE COMPLETED BY SPECIALIST Tooth # Surface Procedures Performed

As a United Concordia Dental member if you visit an in network dentist that dentist will typically submit claims for you If you visit an out of network dentist See instructions for Completing Member Dental Claim Form How to Use Claim Form How to Use Claim Form AZ NY

Submit A Claim Uccitdp

Instructions for Completing Dental Claim Form Completion of this form is only necessary if you visit a non network dentist Network dentists will complete and submit all necessary paperwork for you Please print clearly or type all required information

Oconus Magazines

Yes claims requiring x rays can be transmitted electronically if you have the ability to send the attachment s through one of the attachment warehouse companies that United Concordia works with Contact Dental Electronic Services at 1 800 633 5430 for a listing of these attachment warehouses

Span Class Result Type

United Concordia TDP OCONUS Dental Unit Phone 844 653 4060 P O Box 69452 Fax number 844 827 9926 Harrisburg PA 17106 USA Email TDP OCONUS ucci The family member must sign the appropriate sections of the claim form If the family member is under 18 years old the parent or guardian must sign the form

Highmark Subsidiary United Concordia Welcomes Back Defense Department Dental Contract

Where are the claim forms You can download claim forms for members who plan to visit an out of network dentist Our in network dentists typically submit claims on your employees behalf Was this helpful Need more help Call us at 1 888 320 3316 Access Your Dental Benefits

Please note: Only the claim form should be used to submit claims. TDP Handbook This booklet provides detailed information regarding your TDP benefits and how to manage them. Download TDP Handbook Supplement This booklet provides detailed information regarding your TDP benefits and how to manage them. Download TDP Benefit Brochure

Span Class Result Type

Your MyDentalBenefits account puts info at your fingertips Welcome to your benefit resources Here you can find referral forms dentist recommendation forms and even file claims for non network dentists

United Concordia Claim Form

Where are the claim forms You can download claim forms for members who plan to visit an out of network dentist Our in network dentists typically submit claims on your employees behalf Was this helpful Need more help Call us at 1 888 320 3316 Access Your Dental Benefits

Electronic Claims Submitting claims electronically with our free online tool saves your dental office time and money and enables you to get paid faster TOPD users should use the service links on the TOPD Online Services page Speed eClaim FREE electronic claims submission to United Concordia Quicker processing means you get paid faster

United Concordia Insurance Lawrenceville Dentist That Accept United Concordia Gwinnett Family