Common use of Administrative Appeals Clause in Contracts

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

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