Common use of COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES Clause in Contracts

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 as written comments, documents, records, and other information relating to the Adverse Benefit Determination. Upon Your request and free of charge, we will provide You reasonable access to and copies of all documents, records, and other information relevant to Adverse Benefit Determination. You have the right to appoint an authorized representative to speak on Your behalf in Your Appeals. An authorized representative is a person to whom You have given written consent to represent You in a review of an Adverse Benefit Determination. The authorized representative may be Your treating Provider, if You appoint the Provider in writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P. O. Box 69420 Harrisburg, PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or treatment is determined to be experimental or investigational. First Level Administrative Appeal If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for an Administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the administrative Appeal is overturned, UCD will reprocess Your Claim, if any. If the administrative Appeal is upheld, UCD will inform You of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals If You still disagree with the first level administrative Appeal decision, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Dental Necessity Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess Your Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform You of the right to begin the External Appeal process if the Adverse Benefit Determination meets the criteria. The Dental Necessity Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of Your request; unless it is mutually agreed that an extension of time is warranted. External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage. Requests submitted to Us after four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify You, Your authorized representative, or a Provider authorized to act on Your behalf of its decision. The IRO decision will be considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the extent that other remedies are available under State or Federal law.

COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. ‌‌‌ We want The Claims Administrator wants to know when You are dissatisfied a Plan Participant is unhappy about the care or services received they receive from Blue Cross and Blue Shield the Claims Administrator or one of Louisiana, United Concordia Dental (UCD), or Participating its Providers. If You want to Plan Participants may register a Complaint Complaint, or file a formal written Grievance about Us, UCD the Claims Administrator or a Provider, please refer to Provider by following the procedures outlined 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 for Plan Participants are outlined below, after the Complaint and Grievance proceduresProcedures. There 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 Appeals Appeal process is available for situations where the standard time frame of the standard Dental Necessity Appeal frames would seriously jeopardize the life or health of a covered person or would person, 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 where in 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 opinion of the calltreating Physician, the covered person may experience pain that cannot be adequately controlled while awaiting a standard Appeal decision. To File a Formal Grievance 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 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 description of the event that lead to reason(s) for 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) levelsdenial, 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 as written comments, documents, records, and other information relating to the Adverse Benefit Determination. Upon Your request and free of charge, we will provide You reasonable access to and copies of all documents, records, and other information relevant to Adverse Benefit Determination. You have the right to appoint an authorized representative to speak on Your behalf in Your Appeals. An authorized representative is a person to whom You have given written consent to represent You in a review of an Adverse Benefit Determination. The authorized representative may be Your treating Provider, if You appoint the Provider in writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P. O. Box 69420 Harrisburg, PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or treatment is determined to be experimental or investigational. First Level Administrative Appeal If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt description of the initial Adverse Benefit Determination for an Administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the administrative Appeal is overturned, UCD will reprocess Your Claimstandard, if any. If , applied in denying the administrative Appeal is upheldClaim (for example, UCD if a Medical Necessity standard was used in denying a Claim, the notice will inform You describe the Medical Necessity standard); and a discussion of the right to begin the second level administrative Appeal processdecision for final internal Benefit denials. The administrative Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days • A description of receipt of the Member’s request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative available internal Appeals If You still disagree with the first level administrative Appeal decision, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will and external review the second level administrative Appeals. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appealsprocedures, including information on how to initiate an Appeal. • Contact information for available sources to assist Plan Participants with internal review of the initial Adverse Benefit DeterminationClaims, then an Appeals and external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Dental Necessity Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess Your Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform You of the right to begin the External Appeal process if the Adverse Benefit Determination meets the criteria. The Dental Necessity Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of Your request; unless it is mutually agreed that an extension of time is warranted. External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage. Requests submitted to Us after four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify You, Your authorized representative, or a Provider authorized to act on Your behalf of its decision. The IRO decision will be considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the extent that other remedies are available under State or Federal lawprocedures.

COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. ‌‌‌ We want to know when You are dissatisfied unhappy about the care or services received from Blue Cross and Blue Shield of Louisiana, United Concordia Dental (UCD), Louisiana or Participating one of Our Providers. If You want may wish to register a Complaint or file a formal written Grievance about Us, UCD Us or a Provider, please refer . In addition to the procedures belowright to Appeal, Your Provider is given an opportunity to speak with a UCD dental representative for an Informal Reconsideration of Our coverage decision when the coverage decision concerns Dental Necessity determinations. You Your may be dissatisfied about decisions made regarding Covered Services. UCD considers an Appeal also have the right to review Your file and present evidence or testimony as Your written request to change an Adverse Benefit Determinationpart of the internal Claims and Appeals process. Your Appeal rights are outlined below, after the Complaint and Grievance proceduresProcedures below. There We consider Your request to change Our coverage decision as an Appeal. An Appeal is defined as a request from a Member or their authorized representative to change a previous decision made by Us about Covered Services. Examples of issues that qualify as Appeals include denied Authorizations, Claims denied based on Adverse Determinations of Dental Necessity, or other Benefit determinations. Adverse Benefit determinations include denials of and reductions in Benefit payments. We have an Expedited Appeals Appeal process for situations where the standard time frame of the standard Dental Necessity Appeal frames would seriously jeopardize the Your life or health of a covered person or would person, 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 where in 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 opinion of the call. To File a Formal Grievance A Grievance is a written expression of dissatisfaction with Ustreating physician, 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 covered person may experience pain 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 cannot be considered at any level of review. UCD will determine if Your Appeal is an administrative Appeal or adequately controlled while awaiting 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 as written comments, documents, records, and other information relating to the Adverse Benefit Determination. Upon Your request and free of charge, we will provide You reasonable access to and copies of all documents, records, and other information relevant to Adverse Benefit Determination. You have the right to appoint an authorized representative to speak on Your behalf in Your Appeals. An authorized representative is a person to whom You have given written consent to represent You in a review of an Adverse Benefit Determination. The authorized representative may be Your treating Provider, if You appoint the Provider in writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P. O. Box 69420 Harrisburg, PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or treatment is determined to be experimental or investigational. First Level Administrative Appeal If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for an Administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the administrative Appeal is overturned, UCD will reprocess Your Claim, if any. If the administrative Appeal is upheld, UCD will inform You of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative Appeals If You still disagree with the first level administrative Appeal decision, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative standard Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of That process is outlined following the first level administrative standard internal Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appeals, including an internal review of the initial Adverse Benefit Determination, then an external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Dental Necessity Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess Your Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform You of the right to begin the External Appeal process if the Adverse Benefit Determination meets the criteria. The Dental Necessity Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of Your request; unless it is mutually agreed that an extension of time is warranted. External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage. Requests submitted to Us after four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify You, Your authorized representative, or a Provider authorized to act on Your behalf of its decision. The IRO decision will be considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the extent that other remedies are available under State or Federal lawprocedures.

COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES. ‌‌‌ We want The Claims Administrator wants to know when You are dissatisfied a Plan Participant is unhappy about the care or services received they receive from Blue Cross and Blue Shield the Claims Administrator or one of Louisiana, United Concordia Dental (UCD), or Participating its Providers. If You want to Plan Participants may register a Complaint Complaint, or file a formal written Grievance about Us, UCD the Claims Administrator or a Provider, please refer to Provider by following the procedures outlined 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 for Plan Participants are outlined below, after the Complaint and Grievance proceduresProcedures. There 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 Appeals Appeal process is available for situations where the standard time frame of the standard Dental Necessity Appeal frames would seriously jeopardize the life or health of a covered person or would person, 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 where in 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 opinion of the calltreating Physician, the covered person may experience pain that cannot be adequately controlled while awaiting a standard Appeal decision. To File a Formal Grievance 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; health care Provider; Claim amount, if applicable; and diagnosis and treatment codes (the corresponding meanings of these codes will be provided upon request).  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 description of the event that lead to reason(s) for 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) levelsdenial, 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 as written comments, documents, records, and other information relating to the Adverse Benefit Determination. Upon Your request and free of charge, we will provide You reasonable access to and copies of all documents, records, and other information relevant to Adverse Benefit Determination. You have the right to appoint an authorized representative to speak on Your behalf in Your Appeals. An authorized representative is a person to whom You have given written consent to represent You in a review of an Adverse Benefit Determination. The authorized representative may be Your treating Provider, if You appoint the Provider in writing. You may call UCD if You have questions or need assistance putting Your Appeal in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P. O. Box 69420 Harrisburg, PA 17106-9420 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness or treatment is determined to be experimental or investigational. First Level Administrative Appeal If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt description of the initial Adverse Benefit Determination for an Administrative Appeal. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the administrative Appeal is overturned, UCD will reprocess Your Claimstandard, if any. If , applied in denying the administrative Appeal is upheldClaim (for example, UCD if a Medical Necessity standard was used in denying a Claim, the notice will inform You describe the Medical Necessity standard); and a discussion of the right to begin the second level administrative Appeal processdecision for final internal Benefit denials. The administrative Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days  A description of receipt of the Member’s request; unless it is mutually agreed that an extension of the time is warranted. Second Level Administrative available internal Appeals If You still disagree with the first level administrative Appeal decision, a written request to Appeal must be submitted within sixty (60) days of receipt of the first level administrative Appeal decision. Requests submitted to UCD after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will and external review the second level administrative Appeals. The committee’s decision is final and binding. The committee’s decision will be mailed to You, Your authorized representative, or a Provider authorized to act on Your behalf, within thirty (30) days of the committee meeting. Dental Necessity Appeals Dental Necessity Appeals involve a denial or partial denial based on Dental Necessity, appropriateness, healthcare setting, level of care, or effectiveness or is determined to be experimental or Investigational. We offer two (2) standard levels of Dental Necessity Appealsprocedures, including information on how to initiate an Appeal.  Contact information for available sources to assist Plan Participants with internal review of the initial Adverse Benefit DeterminationClaims, then an Appeals and external review for Adverse Benefit Determinations in the amount of $250.00 or more. Internal Dental Necessity Appeals If You are not satisfied with the original decision, a written request to Appeal must be submitted within one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination for first level Dental Necessity Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD will investigate Your concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess Your Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform You of the right to begin the External Appeal process if the Adverse Benefit Determination meets the criteria. The Dental Necessity Appeal decision will be mailed to You, Your authorized representative, or a Provider authorized by You to act on Your behalf, within thirty (30) days of receipt of Your request; unless it is mutually agreed that an extension of time is warranted. External Dental Necessity Appeals and Rescission of Coverage For Dental Necessity Appeals and Rescission of Coverage, the second level will be handled by an external Independent Review Organization (IRO) that is not affiliated with UCD and randomly assigned by the Louisiana Department of Insurance. You must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If You still disagree with the internal Dental Necessity Appeal decision or Rescission of Coverage, a written request for an External Appeal must be submitted within four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage. Requests submitted to Us after four (4) months of receipt of the internal Dental Necessity Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide the IRO all pertinent information necessary to conduct the Appeal. The external review will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify You, Your authorized representative, or a Provider authorized to act on Your behalf of its decision. The IRO decision will be considered a final and binding decision on both You and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your sole recourse in disputes concerning determinations of whether a service or item is or was Dentally Necessary or Investigational, except to the extent that other remedies are available under State or Federal lawprocedures.