Common use of Dental Appeal Procedures Clause in Contracts

Dental Appeal Procedures. Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the service does not meet our dental necessity guidelines or orthodontics services were not medically necessary. If we deny payment for a service for dental reasons, you will receive the denial in writing. The written denial you receive will explain the reason for the denial and provide specific instructions for filing a dental appeal. Your dentist may file a dental appeal on your behalf. Your dentist can contact the Provider Call Center to initiate the dental appeal or submit the appeal and all applicable clinical documentation to the address below. To file a dental appeal verbally, you may call our Customer Service Department at (401) 453- 4700 or 0-000-000-0000. You may also file a dental appeal in writing. To do so, you must provide the following information: • name, address, and member ID number; • summary of the dental appeal, • 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 service; and • your signature. If a dental appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written dental appeals should be sent to: Blue Cross Dental Attn: Appeals P. O. Box 219 Providence, Rhode Island 02901-0219 You are entitled to the following levels of review when seeking a dental appeal.

Dental Appeal Procedures. Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the service does not meet our dental necessity guidelines or orthodontics services were not medically necessary. If we deny payment for a service for dental reasons, you will receive the denial in writing. The written denial you receive will explain the reason for the denial and provide specific instructions for filing a dental appeal. Your dentist may file a dental appeal on your behalf. Your dentist can contact the Provider Call Center to initiate the dental appeal or submit the appeal and all applicable clinical documentation to the address below. To file a dental appeal verbally, you may call our Customer Service Department at (401) 453- 4700 or 0-000-000-0000. You may also file a dental appeal in writing. To do so, you must provide the following information: •  name, address, and member ID number; •  summary of the dental appeal, •  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 service; and •  your signature. If a dental appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written dental appeals should be sent to: Blue Cross Dental Attn: Appeals P. O. Box 219 Providence, & Blue Shield of Rhode Island 02901Dental Appeals X.X. Xxx 00000 Xxxxxxxxxx, XX 00000-0219 0000 You are entitled to the following levels of review when seeking a dental appeal.

Dental Appeal Procedures. Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the service does not meet our dental necessity guidelines or orthodontics services were not medically necessary. If we deny payment for a service for dental reasons, you will receive the denial in writing. The written denial you receive will explain the reason for the denial and provide specific instructions for filing a dental appeal. Your dentist may file a dental appeal on your behalf. Your dentist can contact the Provider Call Center to initiate the dental appeal or submit the appeal and all applicable clinical documentation to the address below. To file a dental appeal verbally, you may call our Customer Service Department at (401) 453- 4700 or 0-000-000-0000. You may also file a dental appeal in writing. To do so, you must provide the following information: • name, address, and member ID number; • summary of the dental appeal, • 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 service; and • your signature. If a dental appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written dental appeals should be sent to: Blue Cross Dental Attn: Appeals P. O. Box 219 ProvidenceXxx 000 Xxxxxxxxxx, Rhode Island 02901Xxxxx Xxxxxx 00000-0219 0000 You are entitled to the following levels of review when seeking a dental appeal.

Dental Appeal Procedures. Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the service does not meet our dental necessity guidelines or orthodontics services were not medically necessary. If we deny payment for a service for dental reasons, you will receive the denial in writing. The written denial you receive will explain the reason for the denial and provide specific instructions for filing a dental appeal. Your dentist may file a dental appeal on your behalf. Your dentist can contact the Provider Call Center to initiate the dental appeal or submit the appeal and all applicable clinical documentation to the address below. To file a dental appeal verbally, you may call our Customer Service Department at (401) 453- 4700 or 0-000-000-0000. You may also file a dental appeal in writing. To do so, you must provide the following information: •  name, address, and member ID number; •  summary of the dental appeal, •  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 service; and •  your signature. If a dental appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written dental appeals should be sent to: Blue Cross Dental Attn: Appeals P. O. Box 219 ProvidenceXxx 000 Xxxxxxxxxx, Rhode Island 02901Xxxxx Xxxxxx 00000-0219 0000 You are entitled to the following levels of review when seeking a dental appeal.

Dental Appeal Procedures. Appeal is a verbal or written request for us to reconsider a full or partial denial of payment for services that were denied because we determined that the service does not meet our dental necessity guidelines or orthodontics services were not medically necessary. If we deny payment for a service for dental reasons, you will receive the denial in writing. The written denial you receive will explain the reason for the denial and provide specific instructions for filing a dental appeal. Your dentist may file a dental appeal on your behalf. Your dentist can contact the Provider Call Center to initiate the dental appeal or submit the appeal and all applicable clinical documentation to the address below. To file a dental appeal verbally, you may call our Customer Service Department at (401) 453- 4700 or 0-000-000-0000. You may also file a dental appeal in writing. To do so, you must provide the following information: •  name, address, and member ID number; •  summary of the dental appeal, •  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 service; and •  your signature. If a dental appeal is being filed on your behalf, you must send us a notice with your signature, authorizing the individual to represent you in this matter. Written dental appeals should be sent to: Blue Cross Dental Attn: Appeals P. O. Box 219 Providence, Rhode Island 02901-0219 You are entitled to the following levels of review when seeking a dental appeal.