Claims Appeal. If a claim is denied in whole or in part, the Insured will receive written notification of the decision. An explanation of benefits worksheet will be provided by the Company showing the calculation of the total amount payable, charges not payable, and the reason why they are not payable. An Insured may request a review by filing a written application with the Company who will then review the claim and furnish copies of all documents and all reasons and facts relating to the decision. The Insured may then formally appeal the decision by filing a written request to the Company stating their opinion of the issues and other comments. This appeal must be submitted within 60 days of the receipt of written notice of denial. The Company will issue a decision within 60 days of receipt of the Insured’s written request unless special circumstances require an extension. The decision of the Company shall end the appeal procedure under the Company.
Claims Appeal. If You do not agree with the outcome of a processed claim, You may submit an appeal/grievance online at xxx.xxx.xxx. (See Online Forms/Applications.) Alternatively, you can send a completed Appeal/Grievance Form (available at xxx.xxx.xxx) along with all the supporting documents to: International Claims Services Attention: Appeals Department 00000 Xxxxxxx Xxxxxxx, Xxxxx 000 Xxxxxxxx Xxxxx, XX 00000 XXX xxx.xxx.xxx Appeals Procedure For the purposes of this section, any reference to “You”‘, “‘Your”, or Plan Participant also refers to a representative or Provider designated by You to act on Your behalf, unless otherwise noted. The Company has a two-step appeals/grievance procedure for coverage decisions. To initiate an appeal, You must submit a request for an appeal/grievance in writing within 180 days of receipt of a denial notice. You should state the reason why You feel Your appeal or grievance should be approved and include any information supporting Your appeal/grievance. You may send it to the address above, or go to the website where You can complete an appeal form and submit it to Us. Level One Appeal If You are not satisfied with an administrative, Eligibility, rescission of coverage, denial or reduction of benefit or if a health care determination for Pre-Authorization or current care coverage has been denied; You or Your appointed representative has the right to file an appeal or a grievance within 90 days. Your appeal/grievance will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity, clinical appropriateness, or Experimental and/or Investigational will be considered by a health care professional. For level one appeals, We will respond in writing or electronically with a decision within 15 calendar days after We receive an appeal for a required or concurrent care coverage determination (decision). We will respond within 30 calendar days after We receive an appeal for a post service coverage determination. If more time or information is needed to make the determination, We will notify You in writing or electronically to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review. You may request that the appeal process be expedited if, (a) the time frames under this process would seriously jeopardize Your life, health, ability to regain maximum function or in the opinion of Your Physician would cause You severe pain which ca...
Claims Appeal. Delta Dental will notify the Enrollee and his/her Provider if Benefits are denied for services submitted on a Claim Form, in whole or in part, stating the reason(s) for denial. The Enrollee has at least 180 days after receiving a notice of denial to request an appeal or complaint either verbally by calling Delta Dental at 000- 000-0000 or by writing to Delta Dental giving reasons why they believe the denial was wrong. The Enrollee and his/her Provider may also ask Delta Dental to examine any additional information provided that may support the appeal or complaint. Send your appeal or complaint to Delta Dental at the address shown below: Delta Dental Insurance Company P.O. Box 1809 Alpharetta, GA 30023 Delta Dental will send the Enrollee a written acknowledgment within five (5) days upon receipt of the appeal or complaint. Delta Dental will make a full and fair review and may ask for more documents during this review if needed. The review will take into account all comments, documents, records or other information, regardless of whether such information was submitted or considered initially. If the review is of a denial based in whole or in part on lack of dental necessity, experimental treatment or clinical judgment in applying the terms of this Contract, Delta Dental shall consult with a dentist who has appropriate training and experience. The review will be conducted for us by a person who is neither the individual who made the claim denial that is subject to the review, nor the subordinate of such individual. Delta Dental will send the Enrollee a decision within 30 days after receipt of the Enrollee’s appeal or complaint. If the Enrollee believes he/she needs further review of their appeal or complaint, he/she may contact his/her state regulatory agency if applicable. If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the Enrollee may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may also bring a civil action under Section 502(a) of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 000 Xxxxxxxxxxxx Xxxxxx, X.X. Washington, D.C. 20210.
