Common use of Administrative Appeals Clause in Contracts

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered dental services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your dentist did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call Blue Cross Dental Customer Service, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with Blue Cross Dental Customer Service. If you request an administrative appeal, you must do so within one hundred eighty (180) calendar days of receiving a denial of payment for covered dental services. We will acknowledge receipt of your administrative appeal within ten (10) business days. We will conduct a thorough review of your administrative appeal and respond within fifteen (15) calendar days. The letter will provide you with information regarding our determination. Dental Appeals A dental appeal is a request for us to reconsider a full or partial denial of payment for covered dental services because we determined: • the dental service was not dentally necessary or appropriate; • the orthodontic service was not medically necessary; • the service was experimental or investigational. You may request an expedited appeal when the circumstances are an emergency.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered dental services for the following reasons: •  the services were excluded from coverage; •  we determined that you were not eligible for coverage; •  you or your dentist did not follow BCBSRI’s requirements; or •  a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call Blue Cross Dental Customer Service, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with Blue Cross Dental Customer Service. If you request an administrative appeal, you must do so within one hundred eighty (180) calendar days of receiving a denial of payment for covered dental services. We will acknowledge receipt of your administrative appeal within ten (10) business days. We will conduct a thorough review of your administrative appeal and respond within fifteen (15) calendar days. The letter will provide you with information regarding our determination. Dental Appeals A dental appeal is a request for us to reconsider a full or partial denial of payment for covered dental services because we determined: •  the dental service was not dentally necessary or appropriate; •  the orthodontic service was not medically necessary; •  the service was experimental or investigational. You may request an expedited appeal when the circumstances are an emergency.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered dental services for the following reasons: • the services were excluded from coverage; • we determined that you were not eligible for coverage; • you or your dentist did not follow BCBSRI’s requirements; or • a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call Blue Cross Dental Customer Service, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with Blue Cross Dental Customer Service. If you request an administrative appeal, you must do so within one hundred eighty (180) calendar days of receiving a denial of payment for covered dental services. We will acknowledge receipt of your administrative appeal within ten (10) business days. We will conduct a thorough review of your administrative appeal and respond within fifteen (15) calendar daysdays of the date it was received. The letter will provide you with information regarding our determination. Dental Reconsiderations and Appeals A dental reconsideration or appeal is a request for us to reconsider a full or partial denial of payment for covered dental services because we determined: • the dental service was not dentally necessary or appropriate; • the orthodontic service was not medically necessary; • the service was experimental or investigational. You may request an expedited appeal when the circumstances are an emergency.

Administrative Appeals. An administrative appeal is a request for us to reconsider a full or partial denial of payment for covered dental services for the following reasons: •  the services were excluded from coverage; •  we determined that you were not eligible for coverage; •  you or your dentist did not follow BCBSRI’s requirements; or •  a limitation on an otherwise covered benefit exists. You are not required to file a complaint (as described above), before filing an administrative appeal. If you call Blue Cross Dental Customer Service, a Customer Service Representative will try to resolve your concern. If the issue is not resolved to your satisfaction, you may file a verbal or written administrative appeal with Blue Cross Dental Customer Serviceappeal. If you request an administrative appeal, you must do so within one hundred eighty (180) calendar days of receiving a denial of payment for covered dental services. We will acknowledge receipt of your administrative appeal within ten (10) business days. We will conduct a thorough review of your administrative appeal and respond within fifteen sixty (1560) calendar daysdays of the date it was received. The letter will provide you with information regarding our determination. Dental Appeals A dental appeal is a request for us to reconsider a full or partial denial of payment for covered dental services because we determined: •  the dental service was not dentally necessary or appropriate; •  the orthodontic service was not medically necessary; •  the service was experimental or investigational. You may request an expedited appeal when the circumstances are an emergency.