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- Click ‘Get Form’ to open the united concordia dental insurance form in the editor.
- Begin by filling out the HEADER INFORMATION section. Mark all applicable transaction types and provide the Predetermination/Preauthorization Number if available.
- In the POLICYHOLDER/SUBSCRIBER INFORMATION section, enter the policyholder's name, address, and other required details accurately.
- Complete the INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION by providing the company name and address.
- For OTHER COVERAGE, indicate if there is additional dental or medical coverage and fill in relevant details as needed.
- Fill out PATIENT INFORMATION, including relationship to policyholder, patient’s name, date of birth, and gender.
- In RECORD OF SERVICES PROVIDED, document each service rendered with dates, procedure codes, descriptions, and fees.
- Finally, review all entries for accuracy before signing in the AUTHORIZATIONS section to confirm your agreement with the treatment plan.
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| Versions | Form popularity | Fillable & printable |
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| 2013 | 4 Satisfied (39 Votes) |
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How to file a dental claim with United Concordia?
As a United Concordia Dental member, if you visit an in-network dentist, that dentist will typically submit claims for you. Print out a claim form and bring it to your dentist appointment for the dentist to help complete. Once returned to you, youll need to submit the claim form to our mailing address.
Is United Concordia through Blue Cross?
Blue Cross Blue Shield of Rhode Island (BCBSRI) selected United Concordia Dental to become its new dental partner starting in 2016. United Concordia is proud to administer dental benefits to BCBSRIs more than 104,000 members.
How do I contact United Concordia Dental Insurance?
Dental Insurance Company. United Concordia. Need help accessing dental care during a declared State of Emergency? Please call customer service at 1-800-332-0366.
What does United Concordia Dental cover?
100% covered in-network routine cleanings, exams, and X-rays. 3 cleanings per calendar year on the high-option plan. unlimited annual maximum in the high-option plan (excluding orthodontics and implant services) and $1,500 annual maximum in the standard option (excluding orthodontics)
What is the timely filing limit for United Concordia Dental?
Claims should be submitted as soon as possible after treatment, preferably within 30 days. Claims submitted more than 12 months after the month in which the service was provided will be denied. ADSMs submitting their own claims should send it to: United Concordia Companies, Inc.
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