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 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 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 You. To Register a Complaint A Complaint is an oral expression of dissatisfaction with Us, UCD or with Provider services. You may call UCD at 0-000-000-0000 to register a Complaint. UCD will attempt to resolve Your 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 You within thirty (30) business days of receipt of Your written Grievance. Standard Appeal Process Multiple requests to Appeal the same Claim, service, issue or date of service will not be considered at any level of review. UCD will determine if Your Appeal is an administrative Appeal or a Dental Necessity Appeal. The Appeals procedure has two (2) levels, including review by a committee at the second level on an administrative Appeal and a review by an external Independent Review Organization (IRO) on a Dental Necessity Appeal. You are encouraged to provide UCD with all available information to help completely evaluate Your Appeal such ...
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. 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 timeframe 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 a Member is dissatisfied about the care or services he receives from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD)
COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. The grievance process refers to the overall system that includes complaints, grievances and appeals as defined in Article I. Medicaid and BadgerCare enrollees may grieve any aspect of service delivery provided or arranged by the HMO to the HMO and to the Department (described in Sections A and B below). The enrollee may appeal an action as defined in Article I to the HMO, the Department and/or to the Division of Hearings and Appeals as described in section C below.
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.
