Form 5579 Active Duty Dental Program Claim Form

TRICARE ACTIVE DUTY DENTAL PROGRAM CLAIM FORM

OMB No. 0720-0053
OMB approval expires xx/xx/xxxx

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: [email protected].
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.
Privacy Act Statement
This statement serves to inform you of the purpose for collecting your personal information required by ADDP Claim Form and
how it will be used.
Authority: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR Part 199, Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS); DoDD 6490.02E, Comprehensive Health Surveillance; and E.O. 9397 (SSN), as amended.
Purpose: To collect information necessary for completion of you dental readiness examination conducted by a dental provider
and to collect information necessary for the dental provider to submit a claim for payment for the dental services provided to
you.
Routine uses: Your records may be disclosed outside of DoD to investigate waste, fraud, abuse, security and privacy concerns.
Use and disclosure of your records may also occur in accordance with the DoD Blanket Route Uses published at
http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/ and as permitted by the Privacy Act of 1974, as amended
(5 U.S.C. 552a(b)).
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy
Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited
to, treatment, payment, and healthcare operations.
System of records notice: The applicable system of records notices are EDTMA 04, Medical/Dental Care and Claim history Files
(October 27, 2015, 80 FR 65720) published at
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/ and
A0040-5a DASG DoD, Defense Medical Surveillance System (August 19, 2009, 74 FR 41877) published at
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569970/a0040-5a-dasg-dod.aspx
Disclosure: Voluntary. However, failure to provide all the requested information may result in you not meeting dental readiness
requirements and may affect timely payment of dental provider claims.
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.
• 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.

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

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