Claims Appeal Procedure Sample Clauses

Claims Appeal Procedure. If you receive notice of an Adverse Benefit Determination, and if you think that we incorrectly denied all or part of your claim, you or your Dentist should contact our Customer Services Department and ask them to check the claim to make sure it was processed correctly. You may do this by calling the toll-free number, [▇-▇▇▇-▇▇▇-▇▇▇▇ (TTY users call 711)] and speaking to a telephone advisor. You may also mail your inquiry to the Customer Services Department at [P.O. Box 1596, Indianapolis, IN 46206.] When writing, please enclose a copy of your explanation of benefits and describe the problem. Be sure to include your name, telephone number, the date, and any information you would like considered about your claim. This inquiry is not required and should not be considered a formal request for review of a denied claim. We provide this opportunity for you to describe problems and submit explanatory information that might indicate your claim was improperly denied and allow us to correct any errors quickly and without delay. Whether or not you have asked us informally to recheck our initial determination, you can submit your claim to a formal review through the Disputed Claims Appeal Procedure described below. If you receive notice of an Adverse Benefit Determination, you, or your authorized representative, should seek a review as soon as possible, but you must file your request for review within 180 days of the date on which you receive your notice of the Adverse Benefit Determination which you are asking us to review. Please include your name and address, the Insured’s Social Security number, the reason why you believe your claim was wrongly denied, and any other information you believe supports your claim. You also have the right to review this Policy and any documents related to it. If you would like a record of your request and proof that it was received by us, you should mail it certified mail, return receipt requested. The Dental Director, or any other person(s) reviewing your claim, will not be the same as, nor will they be subordinate to, the person(s), who initially decided your claim. The reviewer will grant no deference to the prior decision about your claim, but rather will assess the information, including any additional information that you have provided, as if he/she were deciding the claim for the first time. The reviewer’s decision will take into account all the applicable review procedures for dental claims, including applicable time limits, an...

Claims Appeal Procedure. If a Member’s or Beneficiary’s claim is denied and he wants a review, he must apply to the Committee in writing. That application can include any comment or argument the claimant wants to make. The claimant can either represent himself or herself or appoint a representative, either of whom has the right to inspect all documents pertaining to the claim and its denial. The Committee can schedule any meeting with the claimant or his or her representative that it finds necessary or appropriate to complete its review. The request for review must be filed within 90 days after the denial. If it is not, the denial becomes final. If a timely request is made, the Committee must make its decision, under normal circumstances, within 60 days of the receipt of the request for review. However, if the Committee notifies the claimant prior to the expiration of the initial review period, it can extend the period of review up to 120 days following the initial receipt of the request for a review. All decisions of the Committee must be in writing and must include the specific reasons for its action and the Plan provisions on which its decision is based. If a decision is not given to the claimant within the review period, the claim is treated as if it were denied on the last day of the review period.

Claims Appeal Procedure. Claims Appeals will be processed when presented in writing and should include additional evidence or information that would warrant re-opening and re-adjudicating the claim. Any Bank of America Qualified Claim and any Non Bank of America Qualified Claim that is reopened due to an Initial Appeal will be subject to a new adjusting service fee, unless there is a change to the claim due to an error or omission by The Third Party Administrator. Fees for the adjusting of reopened claims will be billed separately on the monthly invoice and the back-up must show the policy numbers associated with these claims.