Fillable Tricare Retiree Dental Program Overseas Claim Form (Page 2 of 2) in pdf

Completing the TRDP Overseas Claim Form

Most of the TRDP Overseas Claim Form is self-explanatory; however, there are certain fields to which special

attention should be paid to ensure correct processing:

BOX 1. Service Type: Check the appropriate box to indicate if your claim is for services completed or for a predetermination

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(estimate) of services to be performed. The dentist’s original receipt for completed services or statement for

predetermination of services must be attached to the Overseas Claim Form.

BOX 2. Is patient covered by another dental/medical plan?: Check “No” if the family member has no other dental coverage

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and skip to box 10. If the family member has other dental coverage, please check “Yes” and complete boxes 3 through 9 to

include the complete name, date of birth, gender and Social Security number of the insured (“employee/policyholder”);

and group number, amount paid by, and complete name and address of the other insurance plan (“other carrier”).

BOX 10 - 13. Primary enrollee name (last, first, mi) and address, date of birth (mm/dd/yyyy), phone number (including

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country, city and/or area code, e-mail address: Be sure to provide the full name (no nicknames, please) and current,

complete mailing address of the primary enrollee to include APO/FPO and/or street, city, country, postal mailing code.

Please include a phone number (with country code and city code) and/or an e-mail address so that Delta Dental can contact

you with any questions.

BOX 15. Retiree social security number: The sponsor’s (“retiree’s”) nine-digit SSN is required on each Overseas Claim Form

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submitted.

BOX 16 - 17. Patient name (last, first mi), date of birth (mm/dd/yyyy): List patient’s full name (no nicknames, please).

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BOX 20. Relationship to primary enrollee: Check the appropriate box.

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BOX 21. Signature of patient (or parent/guardian), date: The patient must sign and date the appropriate section of the

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Overseas Claim Form. If the patient is under 18 years of age, the parent or guardian must sign and date the form.

BOX 22. Treatment plan: Provide detailed information about the services performed, including applicable tooth number/

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letter and surface, date the service was completed, description of the service provided, appropriate CDT procedure code

that corresponds to the service provided, when possible and the fee charged in local currency or U.S. dollars.

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BOX 25. Indicate currency: Indicate the type of currency billed to patient (local currency or U.S. dollars). Delta Dental will

convert local currency to U.S. dollars based on the date of service (please do not make the conversion yourself) and will

make any applicable reimbursement directly to the enrollee in U.S. dollars based on the date of service.

BOX 26. Dentist name: Please provide the dentist’s full name.

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BOX 28 – 31. Office address, phone number (including country, city and/or area code), fax number (including country,

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city and/or area code), e-mail address: Include the street, city, country and postal mailing code where the services were

performed and the dentist’s phone number (with country code and city code) and/or e-mail address so that Delta Dental

can contact the dentist with any questions.

BOX 32 – 35. Complete applicable boxes for any additional information required to process this claim. If all necessary

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information is not included, your claim may be denied.

General Instructions

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Submit a separate claim form for each family member who receives treatment.

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All Overseas Claim Forms for TRDP covered services should be completed and submitted to Delta Dental as soon as possible

after the service is provided. Claims must be received by Delta Dental within 12 months of the date of service in order to be

processed. Claims received on or after the first day of the month following 12 months of the date of service will be denied.

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For Delta Dental to process your Overseas Claim Form, it must be filled out completely and correctly and must be signed

by the patient (or parent/guardian) and the dentist who provided the services. Note: No signatures are needed If you are

submitting your claim electronically using the new online TRDP Overseas Claim Submission Form.

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The dentist’s receipt for completed services or a statement of predetermined services must be attached for processing.

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Refer to your TRDP Enhanced Program Benefits Booklet for more information on all covered services as well as detailed

information on benefit levels, limitations, exclusions, and overseas claims processing and reimbursement policies.

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For timely processing, submit your completed TRDP Overseas Claim Form and all required attachments

electronically to Delta Dental using the online TRDP Overseas Claim Submission Form. You may also mail your completed

claim to: Delta Dental of California, PO Box 537006, Sacramento, California 95853-7006, United States of America.

Tricare Retiree Dental Program Overseas Claim Form Page 2

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