Form 5579 Form 5579 Active Duty Dental Program Claim Form

UNITED CONCORDIA
Claims Processing
P.O. Box 69429
Harrisburg, PA 17106-9429

Form Approved
OMB No. 0720-0053
Expires xx/xx/xxxx

Web site: www.addp-ucci.com
1. Sex

2. Birthdate
Male

mo

day

year

Female

P
A 3. Active Duty Service Member’s (ADSM) name
middle
last
First
T
I
E 4. Active Duty Service Member's (ADSM) social security no.
N
T 5. Mailing address

8. Program name

Active Duty Dental Program

9. Appointment Control Number
Authorization Number / Referral Number

City, State, Zip
S
E
C
T 6. Telephone number
I
O 7. Rank/Branch of service
N
12. Dentist name
13. Dentist soc. sec. or T.I.N.

10. Email Address
11. I have reviewed the following treatment plan. I authorize release of any information
relating to this claim.

Signature
12a. Provider no.
14. Dentist license no.

12b. NPI #

Date

16. Dentist mailing address -- street address

15. Dentist phone no.

City, State, Zip

D
E Dental Readiness Class: ___________
N
(1) ADSM has good oral health and is not expected to require dental treatment or reevaluation for 12 months.
T
(2) ADSM has some oral conditions, but you do not expect these conditions to result in dental emergencies within 12 months if not treated (i.e., requires prophylaxis,, asymptomatic caries
I
with minimal extension into dentin, edentulous areas not requiring immediate prosthetic treatment).
S
(3) ADSM has oral conditions that you do expect to result in dental emergencies within 12 months if not treated. Examples of conditions are: (X the applicable block or specify in the space provided)
T
(a) Infections: Acute oral infections, pulpal or periapical pathology, chronic oral infections, or other pathologic lesions and lesions requiring biopsy or awaiting biopsy report.
(b) Caries/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective restorations or temporary restorations that patients cannot maintain for
12 months.
(c) Missing Teeth: Edentulous areas requiring immediate prosthodontic treatment for adequate mastication, communication, or acceptable esthetics.
(d) Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis, periodontal abscess, progressive mucogingival condition, moderate to heavy
subgingival calculus, or periodontal manifestations of systemic disease or hormonal disturbances.
(e) Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.
(f) Other: Temporomandibular disorders or myofascial pain dysfunction requiring active treatment.
17. If you selected Block (3) above, please circle the condition(s) you identified in this ADSM if they appear above, or briefly describe the condition(s) below:

S
E
C
T
I
O
N

18.

TOOTH
NO. OR
LETTER

SURFACE

DESCRIPTION OF SERVICES
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED,ETC.)

DATE SERVICE
PERFORMED

MO.

DAY

YR.

PROCEDURE
CODE

20. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties. The signer agrees that any personally identifiable health information about the signer or
signer's enrolled dependents is protected by the Health Insurance Portability and Accountability Act of 1996 and other privacy laws. In accordance with those
laws, United Concordia may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy
Practice.
Signature (Dentist)
5579 (03/10)

Date

FEE
CHARGED

19. TOTAL FEE CHARGED

Completing the ADDP Claim Form
Most of the ADDP Claim form is self-explanatory; however, there are certain fields to which special attention should
be paid.
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Box 4. Active Duty Service Member’s (ADSM) Social Security Number (SSN). The ADSM's
nine-digit SSN must appear on every claim form.
Box 5. Mailing Address. Be sure to provide the current and complete mailing address to include
APO/FPO and/or street, city, country, and postal mailing code.
Box 11. Release of information.
Box 12. Dentist Name and provider number - The provider number represents the provider
number assigned by United Concordia.
Box 16. Dentist address. Include street, city, country, and postal mailing code.
Box 17. Examination Results. The individual you are examining is an Active Duty/Guard/Reserve
member of the United States Uniformed Forces. This ADSM needs your assessment of his/her
dental health for worldwide duty. Please mark (X) the block above this field, that best describe
the condition of the ADSM, using as a suggested minimum a clinical examination with mirror and
probe, and bitewing radiographs. This form is meant to determine fitness for prolonged duty
without ready access to dental care and is not intended to address the ADSM’s
comprehensive dental needs.
Box 18. Provide a detailed description of the services performed including applicable tooth
numbers, dates of service, and fee charged.

General Instructions

Submit a separate claim form for each ADSM who receives treatment.
All claim forms should be submitted to United Concordia as soon as possible after the service date,
preferably within 60 days of the date of service. Claims postmarked more than 12 months after the
date of service will be denied.
The ADSM must sign the appropriate sections of the claim form.
The dentist must sign the appropriate sections of the claim form.

AGENCY DISCLOSURE STATEMENT
The public reporting burden for this collection of information is estimated to average 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of
Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0720-0053). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

Responses should be sent to:
UNITED CONCORDIA
Claims Processing
P.O. Box 69429
Harrisburg, PA 17106-9429

FM55321BEC03101W

PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.