Appeal Levels

There are three levels of appeal: reconsideration, formal review, and hearing.f

Level I: Reconsideration

Reconsideration is a formal request made by beneficiaries and dentists to United Concordia to seek a separate review from the initial payment determination to assess whether the initial payment decision was correct.

How to Request a Reconsideration
The request must be in writing and include all rationale (reason for the request), supporting documentation (e.g., X-rays; dated periodontal charting; clinical narratives; permanent change of station orders, if applicable; progress notes; treatment records), and a copy of the initial determination. The reconsideration request can be submitted online at www.uccitdp.com or mailed to United Concordia. The reconsideration request must be postmarked or received by United Concordia within 90 calendar days of the issue date of the dental explanation of benefits (DEOB). The issue date (claim year and month) is located on the upper right corner of the DEOB. Because the request for reconsideration must be filed within 90 days, the appeal request should not be delayed to obtain supporting records if the records are not readily available. If supporting records will be submitted at a later date, the appeal letter should contain the expected date of submission.

Note: These instructions, as well as the patient’s right to appeal, are also provided on the DEOB. Requests for reconsideration must be submitted separately from dental claim submission documents. If submitted together in the same envelope, the reconsideration will be processed as a claim and denied as a duplicate.

What Happens During a Reconsideration?
United Concordia will review all documentation submitted and conduct a thorough investigation. United Concordia may contact the member or the dentist for additional information and, in some cases, refer the claim to a United Concordia dentist consultant.

The reconsideration may result in full or partial approval of the disputed costs or confirmation of the initial decision. Written notification of the reconsideration decision and the action taken, if any, should be issued within 60 days of the receipt date of the appeal request. The patient will be sent a copy of the reconsideration decision no matter who requested the reconsideration. The TDP network dentist (or non-network dentist who has been appointed as representative or who has benefits assigned to him or her) will also be notified.

Reconsideration requests must be submitted in writing to:

CONUS/OCONUS:
United Concordia - TRICARE Dental Program
P.O. Box 69450
Harrisburg, PA 17106

Fax: 717-635-4565 (CONUS) or 844-827-9926 (OCONUS Toll-Free Dialing Instructions) or 717-635-4520 (OCONUS toll)

Level II: Formal Review

Patients may request a formal review from the Defense Health Agency (DHA) if they disagree with United Concordia’s reconsideration and if the amount remaining in dispute is $50 or more. The letter containing notification of United Concordia’s reconsideration decision will include a notice of the patient’s right to a formal review and instructions on how to request one.

How to Request a Formal Review
A request for a formal review must be postmarked or received by DHA within 60 days from the date of the reconsideration determination. The request must be in writing and include copies of the reconsideration determination and any other information not supplied with the original appeal request. Because the request for formal review must be filed within 60 days, the appeal request should not be delayed to obtain supporting records if the records are not readily available. If supporting records will be submitted at a later date, the appeal letter should contain the expected date of submission.

The request for formal review should be sent to:

Defense Health Agency
Appeals, Hearings, and Claims
Collection Division
16401 E. Centretech Parkway
Aurora, CO 80011-9066

Level III: Hearing

If a patient disagrees with the formal review decision from DHA and the amount in dispute is $300 or more, he or she may request a hearing with DHA. The request must be in writing and include copies of the formal review decision and any other information not supplied with the previous appeal requests. The request must be postmarked or received by DHA within 60 days of the date of the formal review decision (the date on the letter from DHA providing the results of the formal review). Because the request for a hearing must be filed within 60 days, the appeal request should not be delayed to obtain supporting records if the records are not readily available. If supporting records will be submitted at a later date, the appeal letter should contain the expected date of submission.

The request for a hearing should be sent to:

Defense Health Agency
Appeals, Hearings, and Claims
Collection Division
16401 E. Centretech Parkway
Aurora, CO 80011-9066