Common use of Standard Appeal Process Clause in Contracts

Standard Appeal Process. Xxxxx Vision will determine if a Member’s Appeal as either an administrative Appeal or a Medical Appeal. The Member is encouraged to provide Xxxxx Vision with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Determination. We will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his Adverse Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. Box 791 Latham, NY 12110 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations or exclusions. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our first level Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision after sixty (60) days of the first level administrative Appeal decision will not be considered. A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The Committee’s decision is final and binding. The Committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the Committee meeting. Medical Necessity Appeals Medical Necessity Appeals involve a denial or partial denial based on Medical Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of the initial Adverse Benefit Determination for first level Medical Necessity Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the Medical Necessity Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the Medical Necessity Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level Medical Necessity Appeal process.‌ The Medical Necessity Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical Necessity Appeals If a Member still disagrees with the first level Medical Necessity Appeal decision, a written request to Appeal must be submitted within sixty (60) days of the first level Medical Necessity Appeal decision. Requests submitted to Xxxxx Vision after sixty (60) days of the first level Medical Necessity Appeal decision will not be considered. The second level Medical Necessity Appeal will be reviewed by a Provider who holds a non-restricted license issued in the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under review. The decision is final and binding. The decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the review.

Standard Appeal Process. Xxxxx Vision We will determine if a Member’s Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. The Member is encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department United Concordia Dental Appeals Division P. O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 0-000-000-0000 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our If a Member still disagrees with the first level administrative Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. considered.‌‌ A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The Committee’s decision is final and binding. The Committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty five (305) days of the Committee meeting. Medical Dental Necessity Appeals Medical Dental Necessity Appeals involve a denial or partial denial based on Medical Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level We offer the Member two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Medical Dental Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Medical Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the Medical Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the Medical Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level Medical Necessity External Appeal process.‌ process if the Adverse Benefit Determination meets the criteria. The Medical Dental Necessity Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If a the Member still disagrees with the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. The second level Medical You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be reviewed by a Provider who holds a noncompleted within forty-restricted license issued in five (45) days of receipt of the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under reviewExternal Appeal. The decision is final and binding. The decision IRO will be mailed to notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalfbehalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, within thirty (30) days of except to the review.extent that other remedies are available under State or Federal law.‌‌

Standard Appeal Process. Xxxxx Vision Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if a Member’s Your Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Member is Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Your Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide the Member, upon Upon Your request and free of charge, we will provide You reasonable access to, to and copies of, of all documents, records, and other information relevant to his Adverse Determination. The Member has Benefit Determination.‌‌ You have the right to appoint an authorized representative to represent him speak on Your behalf in his Your Appeals. An authorized representative is a person to whom the Member has You have given written consent to represent him You in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s Your treating Provider, if the Member appoints You appoint the Provider in writing.‌‌‌‌ writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. United Concordia Dental Appeals Division P.O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If You are not satisfied with the original decision, a Member written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for an administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If Your administrative Appeal is overturned, UCD will reprocess Your Claim, if any. If the administrative Appeal is upheld, UCD will inform You of Your right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the You, Your authorized representative, or a Provider authorized by You to act on the Your behalf, within thirty (30) days of receipt of the request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals After review of the first level administrative Appeal decision, if You are still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level administrative Appeal. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals‌‌ Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s Your concerns. If the administrative Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Your Claim, if any. If the administrative Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member You of the right to begin the second level administrative External Appeal processprocess if the Adverse Benefit Determination meets the criteria. The administrative Dental Necessity Appeal decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of receipt of the Member’s Your request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative External Dental Necessity Appeals After review For Dental Necessity Appeals, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Our first level Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision, if a Member is still dissatisfied, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision will not be considered. A Member You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals Committee of persons submitted by Your Provider will not involved in previous decisions regarding be accepted without this form completed with Your signature. We will provide the initial Adverse Benefit Determination will review IRO all pertinent information necessary to conduct the second level administrative AppealsAppeal. The Committee’s decision is final and bindingexternal review will be completed within forty-five (45) days of receipt of the External Appeal. The Committee’s decision IRO will be mailed to the Membernotify You, his Your authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days Your behalf of the Committee meetingits decision. Medical Necessity Appeals Medical Necessity Appeals involve a denial or partial denial based on Medical Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of the initial Adverse Benefit Determination for first level Medical Necessity Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the Medical Necessity Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the Medical Necessity Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level Medical Necessity Appeal process.‌ The Medical Necessity Appeal IRO decision will be mailed considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the Member, his authorized representative, extent that other remedies are available under State or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical Necessity Appeals If a Member still disagrees with the first level Medical Necessity Appeal decision, a written request to Appeal must be submitted within sixty (60) days of the first level Medical Necessity Appeal decision. Requests submitted to Xxxxx Vision after sixty (60) days of the first level Medical Necessity Appeal decision will not be considered. The second level Medical Necessity Appeal will be reviewed by a Provider who holds a non-restricted license issued in the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under review. The decision is final and binding. The decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the reviewFederal law.

Standard Appeal Process. Xxxxx Vision We will determine if a Member’s Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. The Member is encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. United Concordia Dental Appeals Division P.O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 0-000-000-0000 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our If a Member still disagrees with the first level administrative Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. considered.‌‌ A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The Committee’s decision is final and binding. The Committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty five (305) days of the Committee meeting. Medical Dental Necessity Appeals Medical Dental Necessity Appeals involve a denial or partial denial based on Medical Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level We offer the Member two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Medical Dental Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Medical Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the Medical Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the Medical Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level Medical Necessity External Appeal process.‌ process if the Adverse Benefit Determination meets the criteria. The Medical Dental Necessity Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If a the Member still disagrees with the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. The second level Medical You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be reviewed by a Provider who holds a noncompleted within forty-restricted license issued in five (45) days of receipt of the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under reviewExternal Appeal. The decision is final and binding. The decision IRO will be mailed to notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalfbehalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, within thirty (30) days of except to the reviewextent that other remedies are available under State or Federal law.

Standard Appeal Process. Xxxxx Vision We will determine if a Member’s Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. The Member is encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. United Concordia Dental Appeals Division P.O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 0-000-000-0000 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our If a Member still disagrees with the first level administrative Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. considered.‌‌ A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The Committee’s decision is final and binding. The Committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty five (305) days of the Committee meeting. Medical Dental Necessity Appeals Medical Dental Necessity Appeals involve a denial or partial denial based on Medical Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level We offer the Member two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Medical Dental Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Medical Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the Medical Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the Medical Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level Medical Necessity External Appeal process.‌ process if the Adverse Benefit Determination meets the criteria. The Medical Dental Necessity Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If a the Member still disagrees with the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. The second level Medical You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be reviewed by a Provider who holds a noncompleted within forty-restricted license issued in five (45) days of receipt of the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under reviewExternal Appeal. The decision is final and binding. The decision IRO will be mailed to notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalfbehalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, within thirty (30) days of except to the review.extent that other remedies are available under State or Federal law.‌‌

Standard Appeal Process. Xxxxx Vision Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if a Member’s Your Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Member is Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Your Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide the Member, upon Upon Your request and free of charge, we will provide You reasonable access to, to and copies of, of all documents, records, and other information relevant to his Adverse Benefit Determination. The Member has You have the right to appoint an authorized representative to represent him speak on Your behalf in his Your Appeals. An authorized representative is a person to whom the Member has You have given written consent to represent him You in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s Your treating Provider, if the Member appoints You appoint the Provider in writing.‌‌‌‌ writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department United Concordia Dental Appeals Division P. O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If You are not satisfied with the original decision, a Member written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for an administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If Your administrative Appeal is overturned, UCD will reprocess Your Claim, if any. If the administrative Appeal is upheld, UCD will inform You of Your right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the You, Your authorized representative, or a Provider authorized by You to act on the Your behalf, within thirty (30) days of receipt of the request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals After review of the first level administrative Appeal decision, if You are still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level administrative Appeal. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s Your concerns. If the administrative Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Your Claim, if any. If the administrative Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member You of the right to begin the second level administrative External Appeal processprocess if the Adverse Benefit Determination meets the criteria. The administrative Dental Necessity Appeal decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of receipt of the Member’s Your request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative External Dental Necessity Appeals After review For Dental Necessity Appeals, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Our first level Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision, if a Member is still dissatisfied, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision will not be considered. A Member You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals Committee of persons submitted by Your Provider will not involved in previous decisions regarding be accepted without this form completed with Your signature. We will provide the initial Adverse Benefit Determination will review IRO all pertinent information necessary to conduct the second level administrative AppealsAppeal. The Committee’s decision is final and bindingexternal review will be completed within forty-five (45) days of receipt of the External Appeal. The Committee’s decision IRO will be mailed to the Membernotify You, his Your authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days Your behalf of the Committee meetingits decision. Medical Necessity Appeals Medical Necessity Appeals involve a denial or partial denial based on Medical Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of the initial Adverse Benefit Determination for first level Medical Necessity Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the Medical Necessity Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the Medical Necessity Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level Medical Necessity Appeal process.‌ The Medical Necessity Appeal IRO decision will be mailed considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the Member, his authorized representative, extent that other remedies are available under State or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical Necessity Appeals If a Member still disagrees with the first level Medical Necessity Appeal decision, a written request to Appeal must be submitted within sixty (60) days of the first level Medical Necessity Appeal decision. Requests submitted to Xxxxx Vision after sixty (60) days of the first level Medical Necessity Appeal decision will not be considered. The second level Medical Necessity Appeal will be reviewed by a Provider who holds a non-restricted license issued in the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under review. The decision is final and binding. The decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the reviewFederal law.

Standard Appeal Process. Xxxxx Vision Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if a Member’s Your Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Member is Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Your Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide the Member, upon Upon Your request and free of charge, we will provide You reasonable access to, to and copies of, of all documents, records, and other information relevant to his Adverse Benefit Determination. The Member has You have the right to appoint an authorized representative to represent him speak on Your behalf in his Your Appeals. An authorized representative is a person to whom the Member has You have given written consent to represent him You in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s Your treating Provider, if the Member appoints You appoint the Provider in writing.‌‌‌‌ writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. United Concordia Dental Appeals Division P.O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If You are not satisfied with the original decision, a Member written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for an administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If Your administrative Appeal is overturned, UCD will reprocess Your Claim, if any. If the administrative Appeal is upheld, UCD will inform You of Your right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the You, Your authorized representative, or a Provider authorized by You to act on the Your behalf, within thirty (30) days of receipt of the request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals After review of the first level administrative Appeal decision, if You are still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level administrative Appeal. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s Your concerns. If the administrative Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Your Claim, if any. If the administrative Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member You of the right to begin the second level administrative External Appeal processprocess if the Adverse Benefit Determination meets the criteria. The administrative Dental Necessity Appeal decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of receipt of the Member’s Your request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative External Dental Necessity Appeals After review For Dental Necessity Appeals, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Our first level Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision, if a Member is still dissatisfied, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level administrative internal Dental Necessity Appeal decision will not be considered. A Member You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals Committee of persons submitted by Your Provider will not involved in previous decisions regarding be accepted without this form completed with Your signature. We will provide the initial Adverse Benefit Determination will review IRO all pertinent information necessary to conduct the second level administrative AppealsAppeal. The Committee’s decision is final and bindingexternal review will be completed within forty-five (45) days of receipt of the External Appeal. The Committee’s decision IRO will be mailed to the Membernotify You, his Your authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days Your behalf of the Committee meetingits decision. Medical Necessity Appeals Medical Necessity Appeals involve a denial or partial denial based on Medical Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of the initial Adverse Benefit Determination for first level Medical Necessity Appeals. Requests submitted to Xxxxx Vision after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision will investigate the Member’s concerns. If the Medical Necessity Appeal is overturned, Xxxxx Vision will reprocess the Member’s Claim, if any. If the Medical Necessity Appeal is upheld, Xxxxx Vision will inform the Member of the right to begin the second level Medical Necessity Appeal process.‌ The Medical Necessity Appeal IRO decision will be mailed considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the Member, his authorized representative, extent that other remedies are available under State or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical Necessity Appeals If a Member still disagrees with the first level Medical Necessity Appeal decision, a written request to Appeal must be submitted within sixty (60) days of the first level Medical Necessity Appeal decision. Requests submitted to Xxxxx Vision after sixty (60) days of the first level Medical Necessity Appeal decision will not be considered. The second level Medical Necessity Appeal will be reviewed by a Provider who holds a non-restricted license issued in the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under review. The decision is final and binding. The decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the reviewFederal law.

Standard Appeal Process. Xxxxx Vision Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if a Member’s Your Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Member is Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Your Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide the Member, upon Upon Your request and free of charge, we will provide You reasonable access to, to and copies of, of all documents, records, and other information relevant to his Adverse Determination. The Member has Benefit Determination.‌‌ You have the right to appoint an authorized representative to represent him speak on Your behalf in his Your Appeals. An authorized representative is a person to whom the Member has You have given written consent to represent him You in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s Your treating Provider, if the Member appoints You appoint the Provider in writing.‌‌‌‌ writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department United Concordia Dental Appeals Division P. O. Box 791 Latham69420 Harrisburg, NY 12110 PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or exclusionstreatment is determined to be experimental or investigational. First Level Administrative Appeals If a Member is You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Administrative Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s Your concerns. If the Your administrative Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Your Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision UCD will inform the Member You of the Your right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals After review of Our the first level administrative Appeal decision, if a Member is You are still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A Member Appeals Committee committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level administrative AppealsAppeal. The Committeecommittee’s decision is final and binding. The Committeecommittee’s decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of the Committee committee meeting. Medical Dental Necessity Appeals Medical Appeals‌‌ Dental Necessity Appeals involve a denial or partial denial based on Medical Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Dental Necessity Appeals We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. If a Member is You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Medical Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s Your concerns. If the Medical Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Your Claim, if any. If the Medical Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member You of the Your right to begin the second level Medical Necessity External Appeal process.‌ process if the Adverse Benefit Determination meets the criteria. The Medical Dental Necessity Appeal decision will be mailed to the MemberYou, his Your authorized representative, or a Provider authorized by You to act on the Member’s Your behalf, within thirty (30) days of receipt of the Member’s Your request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If a Member You still disagrees disagree with the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage, a written request to for an External Appeal must be submitted within sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decisiondecision or Rescission of Coverage. Requests submitted to Xxxxx Vision Us after sixty four (604) days months of receipt of the first level Medical internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. The second level Medical You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be reviewed by a Provider who holds a noncompleted within forty-restricted license issued in five (45) days of receipt of the United States in the same or an appropriate specialty that typically manages the condition, procedure or treatment under reviewExternal Appeal. The decision is final and binding. The decision IRO will be mailed to the Membernotify You, his Your authorized representative, or a Provider authorized to act on Your behalf of its decision. The IRO decision will be considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the Member’s behalf, within thirty (30) days of the reviewextent that other remedies are available under State or Federal law.

Standard Appeal Process. Xxxxx Vision We will determine if a Member’s Appeal as either is an administrative Appeal or a Medical Dental Necessity Appeal. The Member is encouraged to provide Xxxxx Vision UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.‌‌‌‌ writing. All Appeals including administrative Appeals, Dental Necessity Appeals and Medical Necessity Expedited Appeals should be submitted in writing to: Xxxxx Vision Quality Assurance Department P. O. Box 791 LathamUnited Concordia Dental Appeals Division X.X. Xxx 00000 Xxxxxxxxxx, NY 12110 XX 00000-0000 0-000-000-0000 Administrative Appeals Administrative Appeals involve contractual issues other than Medical Dental Necessity denials such as an Adverse Benefit Determinations based on Benefit Plan limitations or exclusions. First Level Administrative Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level administrative Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the administrative Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of Our If a Member still disagrees with the first level administrative Appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of the first level administrative Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of the first level administrative Appeal decision will not be considered. A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The Committee’s decision is final and binding. The Committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty five (305) days of the Committee meeting. Medical Dental Necessity Appeals Medical Dental Necessity Appeals involve a denial or partial denial based on Medical Dental Necessity, appropriateness, healthcare health care setting, level of care, or effectiveness or is determined to be experimental or Investigational. First Level Internal Medical Dental Necessity Appeals If a Member is not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of the initial Adverse Benefit Determination for first level Medical Dental Necessity Appeals. Requests submitted to Xxxxx Vision UCD after one hundred eighty (180) days of the initial Adverse Benefit Determination will not be considered. Xxxxx Vision UCD will investigate the Member’s concerns. If the Medical Dental Necessity Appeal is overturned, Xxxxx Vision UCD will reprocess the Member’s Claim, if any. If the Medical Dental Necessity Appeal is upheld, Xxxxx Vision UCD will inform the Member of the right to begin the second level Medical Dental Necessity Appeal process.‌ process. The Medical Dental Necessity Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Medical Dental Necessity Appeals If a Member still disagrees with the first level Medical Dental Necessity Appeal decision, a written request to Appeal must be submitted within sixty (60) days of the first level Medical Dental Necessity Appeal decision. Requests submitted to Xxxxx Vision UCD after sixty (60) days of the first level Medical Dental Necessity Appeal decision will not be considered. considered.‌‌ The second level Medical Dental Necessity Appeal will be reviewed by a Provider Dentist who holds a non-restricted license issued in the United States in the same or an appropriate specialty that typically manages the dental condition, procedure or treatment under review. The decision is final and binding. The decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the review.