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• Providers must comply with several criteria throughout the ADDP contract to maintain their STAR provider distinction within the ADDP Dental Network Charges ADSMs will have no out-of-pocket costs for approved covered services. • Network dentists will be reimbursed by United Concordia upon completion of claim processing and at United Concordia’s Maximum Allowable Charge Schedule. Treatment DTF-referred: • All DTF referrals require an Appointment Control Number (ACN) provided by United Concordia prior to receipt of private sector care. The ACN remains the same for all treatment listed and any modifications made on the referral. Only those services listed by the DTF may be provided with the following exceptions: • Oral evaluation procedure codes D0120, D0140, or D0150 may be provided for ADSMs once per course of treatment, per provider, if an examination is not prescribed on the referral • 1-2 bitewing radiographic images (D0270 or D0272) or 1-2 periapical radiographic images (D0220 and D0230) may be added • Oral Surgeons may perform a D0330 panoramic radiographic image • Amalgam may be substituted for composite resin in posterior restoration • One surface may be added or removed from a restoration without DTF referral modification; however, an alternate material (resin instead of amalgam) cannot be provided without DTF referral modification • D2750 may be performed as an adequate substitute for D2752 • D2750 may be performed as an adequate substitute for D2790 on teeth #s 3,4,5,6,7,8,9,10,11,12,13,14, 19,20,21,22,23,24, 25,26,27,28,29, and 30 • D2790 may be performed as an adequate substitute for D2792 on molars • A buildup (D2950) or a prefabricated post & core (D2954) may be placed if performed on the same date the RCT is completed by the same provider • D2952 (post & core-custom) and D2954 (post & core-prefab) may be performed as an adequate substitute for buildups D2950 (under single crown) if the tooth has been endodontically treated • D7210 may be performed as an adequate Effective August 1, 2014, United Concordia will begin their five-year renewal contract administering TRICARE Active Duty Dental Program (ADDP). Following are details about the ADDP you need to know: Eligibility The ADDP provides private sector dental care for active duty service members (ADSMs) serving in: • U.S. Air Force • U.S. Army • U.S. Navy • U.S. Marine Corps • U.S. Coast Guard • National Oceanic and Atmospheric Administration (NOAA) Corps • National Guard and Reserve Component sponsors called or ordered to active duty for more than 30 consecutive days and “Early Activators” • Personnel in the Transition Assistance Management Program (TAMP) following activation for a contingency operation for more than 30 days • Foreign military personnel (stationed in the U.S.) • Line of Duty (LOD) service members • Wounded Warriors ADSM eligibility is verified by United Concordia upon appointment request. ADSMs must be on active duty on the date private sector care is received. Program Components The ADDP has two major components: • ADSMs who are referred by a military dental treatment facility (DTF); and • ADSMs not located near a DTF (ie. within 50 miles) are considered “remote.” Network Requirements • The ADDP requires in-network utilization via our ADDP Dental Network; there is no out-of-network benefit. • United Concordia ADDP Dental Network Providers are required to provide access for routine dental care within 21 days of request and 28 days of request for specialty care. ADDP STAR Providers • A subset of pre-selected providers within the ADDP Dental Network • Selected based upon their consistent track record of treating a substantial number of ADSMs without grievances or utilization review concerns, while complying with the ADDP’s efficiency and quality standards Active Duty Dental Program (ADDP) Fast Facts:
