Common use of Complaint and Administrative Appeal Procedures Clause in Contracts

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue;  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coveragecoverage ;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue; ,  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Dental Appeals Xxxx 000 Xxxxxxxx Xxxxxx X.X. Xxx 00000 Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We XX 00000-0000 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747- 3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  because we determined that the services were excluded from coverage;  we failed to make payment (in whole coverage or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern inquiry is not resolved to your satisfaction, you may file a complaint or an administrative appeal verbally with the Customer Service Representativeappeal. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an or administrative appeal, you must do so within one hundred and eighty (180) calendar days from the date of receiving a denial notice of benefitsthe claim determination. You are not required can do so by calling our Customer Service Department at (000) 000-0000 or 1-800-639- 2227. The Customer Service Representative will log your call and the nature of the issue and attempt to file a complaint before filing an administrative appealresolve the problem. You may also file a complaint or administrative appeal in writing. To do sofile a complaint or administrative appeal, you must provide the details of your complaint or administrative appeal and include the following information:  • name, address, member ID number;  • summary of the issue;  complaint or administrative appeal, any previous contact with Blue Cross & Blue Shield of Rhode Island;  Island and a brief description of the relief or solution you are seeking;  • any more additional information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, member Complaint/Administrative appeal form or you can send us a letter with the information requested above. A Customer Service Representative can provide you with a Complaint/Administrative appeal form upon request. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with that the person has the authority to receive information from us on your signature, authorizing the individual to represent you in behalf. You must sign this matternotice. Please mail the complaint complaint, administrative appeal, or administrative appeal notice to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We You will acknowledge receive an acknowledgement letter from us within ten (10) business days of the receipt of your written complaint or administrative appeal. Most verbal complaints are acknowledged by the Customer Service Representative when you make your complaint and you will not receive an acknowledgement letter. The Grievance and Appeals Unit will conduct a thorough review of your Complaint or Administrative appeal. In most cases, the combined time from our receipt of your Complaint or Administrative appeal in writing and sending a written decision to you will not exceed sixty (60) calendar days. Your determination letter from us will provide you with information regarding our determination (decision). Blue Cross & Blue Shield of Rhode Island does not offer any further internal or by phone within tenexternal review, though you may notify the State of Rhode Island Department of Health regarding your concerns or refer to the section for Judicial Review information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue;  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within tenten (10) business days of our receipt of your written complaint or administrative appeal. The Grievance and Appeals Unit will conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below.  Xxxxx 0 We will respond to your Level 1 complaint in writing within thirty (30) calendar days of the date we receive your complaint. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint.  Level 2 (when applicable) A Level 2 complaint may be submitted only when you have been offered a second level of complaint in your Level 1 determination letter. The Grievance and Appeals Unit will conduct a thorough review of your Level 2 complaint and respond to you in writing within thirty (30) business days of the date we receive your Level 2 letter. Our determination letter will provide you with the rationale for our response as well as information on the next steps if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing within sixty (60) calendar days of our receipt of your administrative appeal. The determination letter will provide you with information regarding our determination. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coverage;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or • you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within tenten (10) business days of our receipt of your written complaint or administrative appeal. The Grievance and Appeals Unit will conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. • Level 1 We will respond to your Level 1 complaint in writing within thirty (30) calendar days of the date we receive your complaint. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. • Level 2 (when applicable) A Level 2 complaint may be submitted only when you have been offered a second level of complaint in your Level 1 determination letter. The Grievance and Appeals Unit will conduct a thorough review of your Level 2 complaint and respond to you in writing within thirty (30) business days of the date we receive your Level 2 letter. Our determination letter will provide you with the rationale for our response as well as information on the next steps if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing within sixty (60) calendar days of our receipt of your administrative appeal. The determination letter will provide you with information regarding our determination. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747-3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coverage;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue;  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten;

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coveragecoverage ;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue; ,  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island AttentionDental Attn: Grievance and Appeals Xxxx P. X. Xxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 00000-0000 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747- 3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coveragecoverage ;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Dental Attn: Appeals P. O. Box 219 Providence, Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 02901-0219 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative appeal. You may notify the State of Rhode Island Department of Health or the State of Rhode Island Office of the Health Insurance Commissioner about your concerns. Please refer to the Legal Review section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coveragecoverage ;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island AttentionDental Attn: Grievance and Appeals Xxxx P. X. Xxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 00000-0000 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative appeal. You may notify the State of Rhode Island Department of Health or the State of Rhode Island Office of the Health Insurance Commissioner about your concerns. Please refer to the Legal Review section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coverage;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  the services were excluded from coverage;  we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coveragecoverage ;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  name, address, member ID number;  summary of the issue; ,  any previous contact with Blue Cross & Blue Shield of Rhode Island;  a brief description of the relief or solution you are seeking;  any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  the date of incident or service; and  your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Dental Attn: Appeals P. O. Box 219 Providence, Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 02901-0219 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747- 3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  we determined that you were not initially eligible for coverage;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coverage;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or • you or your provider did not follow Blue Cross & Blue Shield of Rhode IslandBCBSRI’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  • any previous contact with Blue Cross & Blue Shield of Rhode IslandBCBSRI;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx Unit 000 Xxxxxxxx Xxxxxx XxxxxxxxxxProvidence, Xxxxx Xxxxxx 00000 Rhode Island 02903 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coveragecoverage ;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island AttentionDental Attn: Grievance and Appeals Xxxx P. X. Xxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 00000-0000 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747- 3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  • the services were excluded from coverage;  • we failed to make payment (in whole or part) for a service;  • we determined that you were not initially eligible for coveragecoverage ;  • we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  • you or you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  • other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Dental Attn: Appeals P. O. Box 219 Providence, Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 02901-0219 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. BCBSRI does not offer a Level 2 administrative appeal. You may notify the Office of The Health Insurance Commissioner’s Consumer Resource Program, RIREACH at 1-855-747- 3224 about your concerns. Please refer to the Legal Action section below for more information.

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  because we determined that the services were excluded from coverage;  we failed to make payment (in whole coverage or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or because you or your provider did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Customer Service DepartmentDepartment at (000) 000-0000 or 0-000-000-0000. The Customer Service Representative will try log your call and the nature of the issue and attempt to resolve your concern. If it your concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) 180 days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , any previous contact with Blue Cross & Blue Shield of Rhode Island;  Island and a brief description of the relief or solution you are seeking;  • any more additional information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island Attention: Grievance and Appeals Xxxx 000 Xxxxxxxx Xxxxxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We will acknowledge your complaint or administrative appeal in writing or by phone within ten

Complaint and Administrative Appeal Procedures. A Complaint is a verbal or written expression of dissatisfaction with any aspect of our operation or the quality of care you received. A complaint is not an appeal, an inquiry, or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to your satisfaction. An Administrative Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because:  because we determined that the services were excluded from coverage;  we failed to make payment (in whole coverage or part) for a service;  we determined that you were not initially eligible for coverage;  we determined that you were not eligible for coverage (for example, a rescission of coverage occurred);  you or because you or your provider dentist did not follow Blue Cross & Blue Shield of Rhode Island’s requirements; or  other limitation on an otherwise covered benefit. If you are dissatisfied with any aspect of our operation, the quality of care you have received, or you have a request for us to reconsider a full or partial denial of benefits, please call our Appeal DIR DEN (09-10) How To File and Appeal A Claim 23 Customer Service Department. The Customer Service Representative will try to resolve your concern. If it concern is not resolved to your satisfaction, you may file a complaint or administrative appeal verbally with the Customer Service Representative. If you wish to file a complaint related to the quality of care you received, you must do so within sixty (60) days of the incident. If you wish to file an administrative appeal, you must do so within one hundred eighty (180) days of receiving a denial of benefits. You are not required to file a complaint before filing an administrative appeal. You may also file a complaint or administrative appeal in writing. To do so, you must provide the following information:  • name, address, member ID number;  • summary of the issue;  , • any previous contact with Blue Cross & Blue Shield of Rhode Island;  • a brief description of the relief or solution you are seeking;  • any more information such as referral forms, claims, claims or any other documentation that you would like us to review;  • the date of incident or service; and  • your signature. You can use the Member Appeal Form, which contact a Customer Service Representative can provide to you, or you can send us a letter with the information requested above. If someone is filing a complaint or administrative appeal on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Please mail the complaint or administrative appeal to: Blue Cross & Blue Shield of Rhode Island AttentionDental Attn: Grievance and Appeals Xxxx P. X. Xxx 000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, Xxxxx Xxxxxx 00000 We 00000-0000 The Blue Cross Dental Unit will acknowledge conduct a thorough review of your complaint or administrative appeal and respond in the timeframes set forth below. We will respond to your complaint in writing within thirty (30) calendar days of the date we receive your complaint and all necessary documentation to conduct the review. The determination letter will provide you with the rationale for our response as well as information on the next steps available to you, if any, if you are not satisfied with the outcome of the complaint. We will respond to your administrative appeal in writing or by phone within tensixty (60) calendar days of our receipt of your administrative appeal and all necessary documentation to conduct the review. The determination letter or phone call will provide you with information regarding our decision. Blue Cross & Blue Shield of Rhode Island does not offer a Level 2 administrative appeal. You Appeal DIR DEN (09-10) How To File and Appeal A Claim 24 may notify the State of Rhode Island Department of Health or the State of Rhode Island Office of the Health Insurance Commissioner about your concerns. Please refer to the Legal Review section below for more information.