United Concordia’s Review and Appeals Process

United Concordia is known to have an extensive review process at times and many providers have recently expressed their frustration regarding claims processing times and denials for their United Concordia patients. The goal of their review process is to evaluate whether or not services rendered are eligible for payment based on specific plan criteria which can be found in the reference book on UCCI’s provider portal.  

There are two levels in the review process, the initial review and the second review. The services that require review are single crowns, on-lays, fixed partial dentures, impacted third molars, operative periodontics or services United Concordia considers to be "of a complex or questionable nature." 

The initial review is performed by a claims reviewer. In the initial review the claim could be approved in whole or partially. Once the claim has finalized, notification is sent to the patient and the provider in the form of an EOB. If either the provider or patient disagrees with the initial review, a second review can be requested.

The second review is done by one of United Concordia’s Dentist Advisors and is considered a final review. United Concordia will only perform a second review if there is additional information sent to support the claim. If no additional information is received with the request, the review will not be performed. Requests for second review should be clearly labeled "second review" and sent to the following address to ensure that it's handled properly.

Dentist Advisor Unit

United Concordia Companies, INC.

PO Box 69420

Harrisburg, PA 17106

As a provider, you also have the right to request that the Dentist Advisor speak with you during the second review. If you would like to speak with the Dentist Advisor during review, this has to be indicated on the documentation along with a telephone number and time of availability. If you have questions concerning claims that were previously reviewed by a Dentist Advisor, you can call 800-772-1133 to make arrangements to discuss the claim with the Advisor who reviewed your claim or get more information regarding the determination. If you or the patient still disagrees with the second review, an appeal can be submitted either by the patient or by the dentist on behalf of the patient.

In order to appeal a denial, there has to be an amount in dispute (unless otherwise stated by specific state legislation). The amount in dispute should be calculated as the amount of money United Concordia would pay if the services involved had been determined to be payable. Documents sent in should be clearly labeled “appeal” in order to ensure proper processing. All appeals should include additional xrays, perio-charting, and or narratives that offer clarity of the condition seen by the treating provider. The request for the appeal should be sent to the following address. (Please be advised that applied deductibles, the amount considered to be the allowable charge, member eligibility, and max benefits being reached are not issues that can be appealed)

United Concordia Companies, INC.

Members Appeals Department

PO Box 69420

Harrisburg, PA 17106

United Concordia also has what’s known as a “Hold harmless” policy. In cases where United Concordia denies a covered service on the basis that the treatment was not necessary, participating providers cannot bill the patient for the treatment without having a signed informed consent form on file.  The informed consent is an agreement in writing between the provider and the patient. The informed consent should always include:

• The proposed treatment (as specific as possible)
• Any reasonable alternatives to that treatment
• A clear understanding by the patient that a benefit for the requested procedure(s) has been denied through the predetermination process and why (if applicable)
• The amount the patient is agreeing to pay if they decide to go forward with treatment
• The patient’s agreement to proceed with treatment
• Signatures from the both the provider and patient
• Date of signature