Common use of Denials Clause in Contracts

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Service. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentist. A complaint is not an appeal. For information about submitting an appeal, please see the Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your dental treatment with the dentist that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentist, you can call Blue Cross Dental Customer Service for further assistance. You may also call Blue Cross Dental Customer Service if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Service. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We will conduct a thorough review of your complaint and respond within thirty (30) business days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Service. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentist. A complaint is not an appeal. For information about submitting an appeal, please see the Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your dental treatment with the dentist that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentist, you can call Blue Cross Dental Customer Service for further assistance. You may also call Blue Cross Dental Customer Service if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Service. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We will conduct a thorough review of your complaint and respond within thirty (30) business calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentisthealthcare provider. A complaint It is not an appeal. For , an inquiry, or a problem of misinformation which can be resolved promptly by clearing up the misunderstanding, or supplying the appropriate information about submitting an appeal, please see the Appeals section belowto your satisfaction. We encourage you to discuss any concerns or issues you may have about any aspect of your dental medical treatment with the dentist healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentistprovider, you can call Blue Cross Dental Customer Service our Medicare Concierge Team for further assistance. You may also call Blue Cross Dental Customer Service our Medicare Concierge Team if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) business days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member subscriber ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Service. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentist. A complaint It is not an appeal. For , an inquiry, or a problem of misinformation which can be resolved promptly by clearing up the misunderstanding, or supplying the appropriate information about submitting an appeal, please see the Appeals section belowto your satisfaction. We encourage you to discuss any concerns or issues you may have about any aspect of your dental treatment with the dentist that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentist, you can call Blue Cross Dental Customer Service for further assistance. You may also call Blue Cross Dental Customer Service if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Service. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We will conduct a thorough review of your complaint and respond within thirty (30) business calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentisthealthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your dental medical treatment with the dentist healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentistprovider, you can call Blue Cross Dental Customer Service our Medicare Concierge Team for further assistance. You may also call Blue Cross Dental Customer Service our Medicare Concierge Team if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) business days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member subscriber ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: •  a full or partial denial of a benefit; •  a reduction of a benefit; •  a termination of a benefit; •  a failure to provide or make a full or partial payment for a benefit; and •  a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: •  reason for the denial; •  clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and •  instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Service. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentist. A complaint It is not an appeal. For , an inquiry, or a problem of misinformation which can be resolved promptly by clearing up the misunderstanding, or supplying the appropriate information about submitting an appeal, please see the Appeals section belowto your satisfaction. We encourage you to discuss any concerns or issues you may have about any aspect of your dental treatment with the dentist that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentist, you can call Blue Cross Dental Customer Service for further assistance. You may also call Blue Cross Dental Customer Service if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Service. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We will conduct a thorough review of your complaint and respond within thirty (30) business days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: •  your name, address, member ID number; •  the date of the incident or service; •  summary of the issue; •  any previous contact with BCBSRI concerning the issue; •  a brief description of the relief or solution you are seeking; and •  additional information such as claims or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.

Denials. A claim denial, also known as an adverse benefit determination, is any of the following: •  a full or partial denial of a benefit; •  a reduction of a benefit; •  a termination of a benefit; •  a failure to provide or make a full or partial payment for a benefit; and •  a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services), a determination letter will be provided with the following information: •  reason for the denial; •  clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and •  instructions for filing an appeal. If you have questions, please contact Blue Cross Dental Customer Service. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) at 1-855-747-3224 about questions or concerns you may have. Complaints A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentist. A complaint It is not an appeal. For , an inquiry, or a problem of misinformation which can be resolved promptly by clearing up the misunderstanding, or supplying the appropriate information about submitting an appeal, please see the Appeals section belowto your satisfaction. We encourage you to discuss any concerns or issues you may have about any aspect of your dental treatment with the dentist that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentist, you can call Blue Cross Dental Customer Service for further assistance. You may also call Blue Cross Dental Customer Service if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Servicecomplaint. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We will conduct a thorough review of your complaint and respond within thirty (30) business days of the date it was received. The determination letter will provide If you with the rationale for our response as well as information on any possible next steps available wish to you. When filing file a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims or any other documentation that you would like us to review. Please send all information  related to the address listed on the Contact Information section.quality of care you received from a dentist, you must do so within sixty

Denials. ‌ A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not dentally necessary or not medically necessary (orthodontic services)necessary, a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing an a medical appeal. If you have questions, please contact Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. See Section 9 for contact information. You may also contact the Office of the Health Insurance Commissioner’s Consumer Resource Program (RIREACH) Program, RIREACH at 1-855-747-3224 about questions or concerns you may have. Complaints Complaints‌ A complaint is an expression of dissatisfaction with any aspect of our operation or the quality of care you received from a dentisthealthcare provider. A complaint is not an appeal. For information about submitting an appeal, please see the Reconsiderations and Appeals section below. We encourage you to discuss any concerns or issues you may have about any aspect of your dental medical treatment with the dentist healthcare provider that furnished the care. In most cases, issues can be more easily resolved if they are raised when they occur. However, if you remain dissatisfied or prefer not to take up the issue with your dentistprovider, you can call Blue Cross Dental our Customer Service Department for further assistance. You may also call Blue Cross Dental our Customer Service Department if you are dissatisfied with any aspect of our operation. If the concern or issue is not resolved to your satisfaction, you may file a verbal or written complaint with Blue Cross Dental Customer Serviceour Grievance and Appeals Unit. We will acknowledge receipt of your complaint or administrative appeal within ten (10) business days. We The Grievance and Appeals Unit will conduct a thorough review of your complaint and respond within thirty (30) business calendar days of the date it was received. The determination letter will provide you with the rationale for our response as well as information on any possible next steps available to you. When filing a complaint, please provide the following information: • your name, address, member ID number; • the date of the incident or service; • summary of the issue; • any previous contact with BCBSRI concerning the issue; • a brief description of the relief or solution you are seeking; and • additional information such as claims referral forms, claims, or any other documentation that you would like us to review. Please send all information to the address listed on the Contact Information section.