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Helpful Forms for Dentists | United Concordia

Helpful Forms for Dentists


Claim Forms

United Concordia encourages you to submit claims electronically. However, if you must submit a paper claim, please follow the instructions posted on the ADA website ( to obtain and complete the form. Additionally, United Concordia is using advanced technology to read the data on paper claims so it is important that you follow the guidelines for completing a paper claim form listed below.


Dentist Advisor Guidelines

The Dentist Advisor Guidelines PDF are a set of clinical guidelines applied during claim review. The clinical guidelines are detailed by procedure type.


Guidelines for completing the ADA 2006 or 2012 claim form

The following changes to the paper submissions process will be effective June 1, 2013:


  • Only the 2006 or 2012 ADA claims form will be accepted for processing; if any other claim form is received, it will be considered a non standard form and will be returned to your office.
  • This change does not apply to services that have already been predetermined; please continue to submit the predetermination form for these services when submitting for payment.
  • ADA claim forms can be obtained by accessing the ADA website at
  • DHMO capitation reports listing single or multiple patients will be returned to your office.
  • Multiple patients received on one ADA claim form and invoice will be returned to your office.
  • National Electronic Attachment (NEA), Renaissance Systems and Services, LLC (RSS) and  Tesia Clearinghouse, LLC attachment control numbers should only be reported on electronic claims; if a paper claim is received with an attachment control number, the attachment will not be viewed.
  • When submitting an Explanation of Benefit (EOB), a completed ADA 2006 or ADA 2012 claim form must accompany the EOB. If only the EOB is  submitted, it will be returned to your office.
  • When preparing your paper claims for submission, please do not write your claims out by hand. Handwritten claims delay system processing.
  • When submitting the ADA 2006 or 2012 claim form with an indication of other insurance, attach the Primary Carrier Explanation of Benefits (EOB) to the claim. There is no need to indicate “Primary Insurance Payment” in the “Record of Services Provided” area on the claim form  .
  • The upper-right corner of the ADA 2006 or 2012 claim form should be left blank to leave space to imprint the claim number when the document is imaged.


Where to submit claim forms

Paper claim forms should be submitted to the address listed on the back of the member’s ID card.


Referral Forms

Use the forms below to refer your patients to specialists for specialty care.


Medicare Advantage Non-Contracted Provider Forms


Medication Substitution Reimbursement Request Form (LA Oral/Maxillofacial Surgeons only)

If you are an oral and maxillofacial surgeon practicing in Louisiana, you may be entitled to reimbursement if you agree to a substitution for a medication that you prescribed when a managed care organization has requested or required that substitution. Reimbursement is not available for medication substitutions made as part of a generic substitution or step therapy program. Use this form to request reimbursement if you are contacted about a substitution for a prescribed medication.


Dental Benefit Limit Exception (BLE) Request Form

A benefit limit exception assures consistent coverage determinations for Medical Assistance members age 21 years and older who have a full benefit package. This does not apply to Medical Assistance members under the age of 21 or members residing in a nursing home or an intermediate care facility. To request a Benefit Limit Exception, this form should be submitted along with a completed ADA claim. For more information on the BLE process refer to the Gateway Health Medicaid Dental Reference Guide.PDF icon


Other useful tools

Read up on the latest dentist news in our Connection newsletter

See how easy it is to submit claims electronically

Why you need a National Provider Identifier (NPI)

Get paid faster with EFT

Quickly view your payments and EOBs