United Concordia Dental

ERA Enrollment Maintenance Form

United Concordia values your business and strives to provide outstanding and timely customer service.

We welcome your feedback

Reporting Fraud

If an EXACT match of the submitted data isn't found in our system, it's possible this request may not be processed.

To help ensure the request is in effect for the regularly scheduled Thursday payment cycle (exceptions can be holidays), please submit requests by noon Wednesday (ET).

Provider Name is required.
Line 1 is required.
Line 2 cannot exceed 37 characters.
Provider City is required.
Provider State is required.
Provider ZIP is required.
Provider TIN or EIN is required.
National Provider Identifier (NPI) is required.
Provider Prefers TIN or NPI is required.
Trading Partner ID is required.
Provider Contact Name is required.
Must use a 10 digit number.
(optional)
Ext cannot exceed 5 characters.
Provider Email is required.
Confirm Provider Email is required.

Clearinghouse Information

Type of Request is required.
Contact Name is required.
Must use a 10 digit number.
(optional)
Ext cannot exceed 5 characters.
Email is required.
Confirm Email is required.
Printed Name of Authorized Person Submitting Enrollment is required.
Authorized to Make Request is required.
Submit

Non-Discrimination Notice

United Concordia Dental complies with all applicable federal civil rights laws.

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