DoD (98 & 99)-Effective 02/18 Page 1 of 2
Participating Dentist Agreement with
United Concordia Companies, Inc. for the
Department of Defense (DoD) Programs
Under the applicable laws of the State of _________________, I am duly
authorized to engage in the practice of dentistry. In consideration for
being registered as a participating dentist in the Department of Defense
(DoD) Networks (i.e. Active Duty Dental Program (ADDP) Network and/or
TRICARE Dental Program (TDP) Network) of United Concordia
Companies, Inc. and its affiliates (collectively, “United Concordia”), I
(“Dentist”) do hereby agree as follows:
1.a. Dentist acknowledges that United Concordia, on consideration of
certain Selection Criteria, may decline to enroll, or to retain,
providers in the TDP and/or ADDP Network. Dentist shall submit a
Credentialing Application attesting to information relevant to the
Selection Criteria upon application for acceptance to the ADDP
and/or TDP Network, and thereafter upon request. The Selection
Criteria will comply with any state regulatory requirements (which
may differ depending on Dentist’s state of licensure) and will be
available to all participating dentists. Dentists may appeal any
decision regarding selection or retention for the Network through
United Concordia’s appeal process.
b. Dentist represents and warrants that he/she is licensed to practice in
the aforementioned State and that such license has not been
suspended, revoked or limited within the past five (5) years. Dentist
further represents and warrants that his/her employees and facilities
are licensed to the extent required by State law and shall only
provide those services to TDP and/or ADDP members (“Members”)
as defined within the scope of their respective licenses. All of
Dentist’s rights and United Concordia’s obligations under this
Agreement are conditioned upon Dentist’s and his/her employees
continued maintenance of such licensure with no restrictions. United
Concordia may begin the process to terminate this Agreement
immediately upon notice if Dentist’s license is suspended, revoked or
limited in any way or if Dentist’s conduct may result in immediate
injury or damage to the health/safety of any Member.
c. During the term of this agreement, the Dentist agrees to maintain
professional liability insurance at: (a) the level required by any
applicable state mandate, (b) $200,000 per occurrence and
$600,000 for aggregate occurrences, or (c) other level acceptable to
United Concordia, based on accepted standards in Dentist’s
geographic area and risk factors applicable to Dentist’s practice.
d. Dentist agrees to accept communications from United Concordia via
mail, facsimile or email at the addresses/numbers shown on
Dentist’s Credentialing Application.
2. Dentist agrees to participate at all practice locations with all DoD
Programs they are participating in that are administered by United
Concordia. Dentist will comply with all policies and procedures
governing United Concordia’s administration of the ADDP and/or
TDP including, but not limited to: claim submission, complaints,
grievances, utilization review, and quality management, as set forth
in the most current version of the Dental Reference Guide, as it may
be amended from time to time. The most current version of the
Dental Reference Guide will be available for review on United
Concordia’s ADDP and/or TDP website (s), www.addp-ucci.com and
www.uccitdp.com.
3. Dentist agrees to report all covered services for eligible Members on
a timely basis following the date the services were rendered using an
ADA claim form or other form acceptable to United Concordia.
Dentist will include the Dental Readiness Classification on each
claim and, upon request, complete the DD Form 2813 for all Active
Duty Service Members, National Guard and Reserve Services
Members at no additional cost to the Member.
4. Dentist agrees to accept his/her charge or the United Concordia
Maximum Allowable Charge, whichever is lower, as payment in full
for covered services. In agreeing to this provision, Dentist
understands that the most current applicable versions of the
Maximum Allowable Charge (MAC) schedules will apply to
reimbursement for all covered services. The current schedule of
Maximum Allowable Charges, and dental policies that may affect the
manner in which such charges are billed and reimbursed, are
available on United Concordia’s ADDP and/or TDP web site (s),
www.addp-ucci.com and www.uccitdp.com.
5. Dentist may bill a Member for non-covered services, which are
defined as any service for which no payment is made under the
applicable plan or arrangement for any reason. Dentist agrees that
his/her charge to Member for non-covered services will not exceed
the Maximum Allowable Charge for the applicable CDT code as
specified in the most current Maximum Allowable Charge schedule.
Fees for all non-covered services will be collected from the Member,
and not billed to United Concordia. With regard to the TDP only,
following exhaustion of any TDP Member’s annual dental benefit
maximum or the lifetime orthodontic benefit maximum, Dentist will
accept as payment in full for any additional services the MAC
applicable to the TDP Dental Network. Payment for all services in
excess of TDP maximums are collected from the TDP Member.
6. Dentist agrees that the services provided and charges made to these
Members shall be consistent with those to his/her other patients.
7. Dentist may not bill a Member for charges itemized and distinguished
from the professional services provided, including but not limited to,
office overhead expenses, fees for completing claim forms, OSHA
compliance surcharges, or costs of submitting additional information
to United Concordia.
8. Dentist will not attempt to collect payment from any Member for any
covered service that is denied as medically or dentally unnecessary
or not meeting accepted standards of practice and the Member will
be held harmless from any financial liability, unless the Member is
informed by the Dentist in advance of receiving the service that the
service is excluded or excludable from coverage, and the Member
agrees to pay for the service. Such agreement to pay by the Member
shall be evidenced in writing, either by written agreement or in clinical
notes entered into the patient’s clinical record contemporaneously
with the time, date of agreement and the Member’s signature. The
Member’s agreement to receive such services, without written
evidence of the enrollee’s agreement to pay notwithstanding
exclusion from coverage, shall not constitute a waiver of the
Member’s right to be held harmless.
9. Dentist shall be responsible, at all times, for maintaining emergency
coverage provided in accordance with the guidelines of the ADA or
applicable state laws.
10. Dentist will maintain accurate and complete dental records for all
Members enrolled in the Plan.
11. Dentist shall furnish any information deemed necessary by United
Concordia to make determinations of coverage and shall permit
United Concordia representatives to make reasonable examinations
of his/her clinical records, including x-rays, relating to covered
services when such examination is necessary to resolve any
question concerning such services. Dentist will cooperate with
United Concordia in timely scheduling appointments for Members to
satisfy ADDP and/or TDP requirements.
12. Dentist is not an employee of United Concordia and United
Concordia shall do nothing to interfere with the customary
