TRICARE Dental Anesthesia Benefit

The TRICARE dental benefit now covers anesthesia and institutional costs for children age 5 and younger and beneficiaries with developmental, mental or physical disabilities. For these patients, it is medically or psychologically necessary to require general anesthesia for dental procedures. TRICARE Dental

Beneficiaries must have a preauthorization for a separate anesthesiology provider; dentists may not administer the anesthesia. This preauthorization is required in the same manner as required for adjunctive dental care.

Retroactive Reimbursements for TRICARE Beneficiaries

Beneficiaries who received care on or after October 17, 2006 through the implementation of the program on July 1, 2007 and believe they should be reimbursed according to the new guidelines may file DD Form 2642 (Beneficiary Claim Form) with copies of the provider’s bill and receipt for payment of services.

To obtain DD Form 2642:

Find a Form
Call 1-888-TRIWEST (874-9378) to have one mailed to you
Visit your local TRICARE Service Center

Billing information must include all of the following:

Specific name and address of the person who treated the patient
Date and place of service
Description of service furnished
Charges for services
Diagnosis (If the diagnosis is not on the bill, complete block 8a on the DD Form 2642.)

Beneficiaries filing for reimbursement for services obtained from October 17, 2006 through July 1, 2007 are not required to have a preauthorization.

Mail completed forms to:

West Region Claims
P.O. Box 77028
Madison, WI 53707-7028

For information on TRICARE’s dental programs:

Active duty, activated Guard and Reserve and their families should contact United Concordia at www.tricaredentalprogram.com or 1-800-866-8499
Retirees and their families should contact Delta Dental at www.trdp.org or 1-888-838-8737