COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD) or Participating Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us, UCD or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal as the Member’s written request to change an Adverse Benefit Determination. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions We make regarding Covered Services. We consider an Appeal as the Member’s request to change an Adverse Benefit Determination made by the Company. Your Appeal rights are outlined below, after the Complaint and Grievance procedure. In addition to the Appeals rights, the Member’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of Our coverage decision when they concern Medical Necessity determinations. We have expedited Appeals processes for situations where the time frame of the standard medical Appeals would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when You are dissatisfied about the care or services received from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD), or Participating Providers. If You want to register a Complaint or file a formal written Grievance about Us, UCD or a Provider, please refer to the procedures below. You may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal as Your written request to change an Adverse Benefit Determination. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. 29 UNDERSTANDING THE BASICS OF YOUR COVERAGE The Schedules of Dental Benefits control in regards to which dental Benefits are covered, the Waiting Period that is applicable to each Benefit, and the cost sharing (deductibles, coinsurance) applicable to each Benefit. The Schedule will describe the Section to which it apples. The Benefits offered under both of these Sections are limited as stated in each Section. UNITED CONCORDIA DENTAL United Concordia Companies, Inc. d/b/a United Concordia Dental (hereinafter “United Concordia Dental” or “Claims Administrator”) is the Blue Cross and Blue Shield of Louisiana’s network and claims administrator for the dental Benefits provided in this Contract, and is in charge of managing the Dental Network, handling and paying claims, and providing customer services to the Members eligible to receive these benefits and their legal representatives. The Dental Network consists of a select group of Providers who have contracted with United Concordia Dental to render services to Members for discounted fees. All other Providers are considered Non-Participating. Non- Participating Providers may bill you more for their services than Participating Providers. In order to receive the full benefits under this Contract, the Member should verify that a Provider is a United Concordia Dental Network Participating Provider before any service is rendered. To locate a Participating Provider and verify their continued participation in the United Concordia Dental Network, or to ask any questions related to Benefits or claims, please visit the website at xxx.xxxxxx.xxx or contact a customer service representative at (000) 000-0000. We”, “Us” and “Our” in this Contract means the Company or United Concordia Dental when it acts on behalf of Blue Cross and Blue Shield of Louisiana in performing its services under the dental coverage provided for in this Section. Capitalized words are defined terms as described below.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is unhappy about the care or services he receives from Blue Cross and Blue Shield of Louisiana or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us or a Provider, please refer to the procedures below. A Member may be unhappy about decisions We make regarding Covered Services. We consider the Member’s request to change Our coverage decision as an Appeal. We define an Appeal as a request from a Member or authorized representative to change a previous decision made by the Company about covered services. Examples of issues that qualify as Appeals include denied Authorizations, Claims based on Adverse Determinations of Medical Necessity, or Benefit determinations. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. In addition to the Appeals rights, the Member’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of Our coverage decision when they concern Medical Necessity determinations. We have an Expedited Appeals process for situations where the time frame of the standard Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. The Claims Administrator wants to know when a Plan Participant is unhappy about the care or services they receive from the Claims Administrator or one of its Providers. Plan Participants may register a Complaint, or file a formal written Grievance about the Claims Administrator or a Provider by following the procedures outlined below. Appeal rights for Plan Participants are outlined after the Complaint and Grievance Procedures. The Plan considers a Plan Participant’s request to change a coverage decision as an Appeal. An Appeal is defined as a request from a Plan Participant or their authorized representative to change a previous decision made by the Claims Administrator about Covered Services. Examples of issues that qualify as Appeals include denied Authorizations, Claims denied based on adverse determinations of Medical Necessity, or other adverse Benefit determinations. Adverse Benefit determinations include denials of and reductions in Benefit payments. In addition to the right to Appeal, the Plan Participant’s Provider is given an opportunity to speak with a Medical Director for an Informal Reconsideration of the Claims Administrator’s coverage decisions when the coverage decision concerns Medical Necessity or Investigational determinations. The Plan Participant may also have the right to review their file and present evidence or testimony as part of the internal Claims and Appeals process. An Expedited Appeal process is available for situations where the standard time frames would seriously jeopardize the life or health of a covered person, jeopardize the covered person’s ability to regain maximum function, or where in the opinion of the treating Physician, the covered person may experience pain that cannot be adequately controlled while awaiting a standard Appeal decision. That process is outlined following the first and second level Appeal procedures in Section B of this Article. The Claims Administrator will respond to your Appeal request within the timeframes allowed by law. The Appeal response will provide information sufficient to identify the Claim and include the following: • The date of service; healthcare Provider; Claim amount, if applicable; and diagnosis and treatment codes (the corresponding meanings of these codes will be provided upon request). • A description of the reason(s) for the denial, including a description of the standard, if any, applied in denying the Claim (for example, if a Medical Necessity standard was used in denying...
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana, Xxxxx Vision or one of Our Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us, Xxxxx Vision or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions made regarding Covered Services. Xxxxx Vision considers the Member’s request to change Our coverage decision as an Appeal. We define an Appeal as a written request from a Member or authorized representative to change a previous decision made by Us about covered services. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Medical Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. We want to know when You are dissatisfied about the care or services received from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD), or Participating Providers. If a Member wants to register a Complaint or file a formal written Grievance about Us, UCD or a Provider, please refer to the procedures below. A Member may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal as the Member’s written request to change an Adverse Benefit Determination. Your Appeal rights are outlined below, after the Complaint and Grievance procedures. There is an Expedited Appeals process for situations where the time frame of the standard Dental Necessity Appeal would seriously jeopardize the life or health of a covered person or would jeopardize the covered person’s ability to regain maximum function. Complaint and Grievance Procedures A quality of service concern addresses Our services, access, availability or attitude and those of Participating Providers. A quality of care concern addresses the appropriateness of care given to a Member. To Register a Complaint A Complaint is an oral expression of dissatisfaction with Us, UCD or with Provider services. Members may call UCD at 0-000-000-0000 to register a Complaint. UCD will attempt to resolve the Member’s Complaint at the time of the call. To File a Formal Grievance A Grievance is a written expression of dissatisfaction with Us, UCD or with Provider services. If You do not feel Your Complaint was adequately resolved or You wish to file a formal Grievance, You must submit this in writing within one hundred eighty (180) days of the event that lead to the dissatisfaction. UCD Customer Service Department will assist You if necessary. Send Your written Grievance to: United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 A response will be mailed to the You within thirty (30) business days of receipt of Your written Grievance.
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. 34 ERISA RIGHTS 37 MAKING PLAN CHANGES AND FILING CLAIMS 38 ARTICLE II. GENERAL PROVISIONS – GROUP/POLICYHOLDER ONLY 40 ARTICLE I. UNDERSTANDING THE BASICS OF YOUR COVERAGE Blue Cross and Blue Shield of Louisiana (Company) issues this Benefit Plan to the Group/Policyholder, as shown in the Schedule of Vision Benefits. A copy of this Benefit Plan provided to Subscribers serves as the Subscriber’s certificate of coverage. The vision Benefits available under this Benefit Plan are described in Article IV. The Schedule of Vision Benefits controls in regards to the Benefits covered, the frequency with which they are covered, and the cost sharing applicable to each Benefit, among other things. A Subscriber must meet the employer’s Eligibility Waiting Period before coverage is effective on this Benefit Plan. The Group may apply to the Company to change the covered Benefits on the Group's anniversary date. Benefits offered may be limited. As of the later of the Original Effective Date or the Amended Effective Date of the Benefit Plan shown in the Group’s Schedule of Vision Benefits, We agree to provide the vision Benefits specified herein for Subscribers of the Group and their enrolled Dependents. This Benefit Plan replaces any others previously issued to the Group/Policyholder. A word used in the masculine gender applies also in the feminine gender, except where otherwise stated. Except for necessary technical terms, We use common words to describe the Benefits provided under this Benefit Plan. “We”, “Us” and “Our” means Blue Cross and Blue Shield of Louisiana. Capitalized words are defined terms in Article II “Definitions.” THE XXXXX VISION NETWORK Xxxxx Vision, Inc. (hereinafter, “Xxxxx Vision) is the Company’s network and claims administrator for this Benefit Plan, and is in charge of managing the Xxxxx Vision Network, handling and paying claims, and providing customer services to the Members eligible to receive coverage under this Benefit Plan. The Xxxxx Vision Network consists of a select group of Providers who have contracted with Xxxxx Vision to render services to Members for discounted fees. All other Providers are considered Non-Participating. THIS BENEFIT PLAN COVERS SERVICES OR MATERIALS RECEIVED FROM NON-PARTICIPATING PROVIDERS AT THE REDUCED BENEFITS SPECIFIED IN THE SCHEDULE OF VISION BENEFITS. In order to receive the full benefits under this section, the Member should verify that a Provider is a Xxxxx Vision Network Participating Provider before ...
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. CBH shall develop, implement and maintain a complaint and grievance system which provides for informal settlement of Members’ complaints and grievances at the lowest administrative level and a formal process for appeal (“Member Complaint and Grievance System”). The development and implementation of the Member Complaint and Grievance System shall be in complete accordance with the Commonwealth Contract and Applicable Law.
