Common use of Disputed Claims Procedure Clause in Contracts

Disputed Claims Procedure. After you have followed the General Claims Inquiry procedure and have reason to believe your benefit determination was not in accordance with the Agreement between Northeast Delta Dental and your group, you have the option of using Northeast Delta Dental’s Disputed Claims Procedure. This may be requested within six (6) months of the date of Northeast Delta Dental’s original Explanation of Benefits. It is recommended that your written request for a review of your claim be personally delivered or mailed certified mail, return receipt requested, to the Vice President, Professional Relations, Northeast Delta Dental, One Delta Drive, PO Box 2002, Concord, New Hampshire, 03302-2002 but you may also submit your request by standard mail. Your request for a review of your claim should refer to the claim(s) in question, state your name and address, and the reasons you think the denial should be evaluated, and provide any additional materials you wish to present. The Vice President, Professional Relations, or his/her designee, may request additional documents as necessary to make such a review and will promptly review your claim. If the claim is wholly or partially Denied, you will be furnished with a notice of the decision within thirty (30) days after receipt of the disputed claim. The written notice will include: 1. The specific reason(s) for denial. 2. The specific reference to the provision upon which the denial is based. If your request for review results in an additional payment, it will be made within fifteen (15) working days of the Vice President, Professional Relations’ response. If you do not receive notice within the thirty (30) day period, the claim is considered Denied in order that you may proceed to the Disputed Claims Review Procedure. If you have any problem securing a review of your claim, contact your group for assistance.

Disputed Claims Procedure. After If you have followed the General Claims Inquiry procedure and have reason to believe your benefit determination was not in accordance with the Agreement between Northeast Delta Dental and terms of your groupplan, you have the option of using Northeast Delta Dental’s Disputed Claims Procedure. This may be requested within six (6) months of the date of Northeast Delta Dental’s original Explanation of Benefits. It is recommended that your written request for a review of your claim be personally delivered or mailed certified mail, return receipt requested, to the Vice PresidentDirector, Professional Relations, Northeast Delta Dental, One Delta DriveXxx Xxxxx Xxxxx, PO Box XX Xxx 0000, Xxxxxxx, Xxx Xxxxxxxxx, 00000- 2002, Concord, New Hampshire, 03302-2002 but you may also submit your request by standard mail. Your request for a review of your claim should refer to the claim(s) in question, state your name and address, and the reasons you think the denial should be evaluated, and provide any additional materials you wish to present. The Vice President, Professional Relations, or his/her designee, may request additional documents as necessary to make such a review and will promptly review your claim. If . i. the claim is wholly or partially Denied, you will be furnished with a notice of the decision within thirty (30) days after receipt of the disputed claim. The written notice will include: 1. The specific reason(s) for denial., and 2ii. The the specific reference to the provision of this Agreement upon which the denial is based. If your request for review results in an additional payment, it will be made within fifteen (15) working days of the Vice Presidentresponse from the Director, Professional Relations’ response, or his/her designee. If you do have not receive notice received a written response within the thirty (30) day period, and/or disagree with the claim is considered Denied in order that response you received, you may proceed to the Disputed Claims Review ProcedureProcedure in Section C below. If you have any problem securing a review of your claim, contact your group for assistance.you may also contact: Community Health Options Mail Stop 100 Attn: Member Services PO Box 1121 Lewiston, ME 04243 Telephone: 0-000-000-0000 (TTY/TDD: 711) Fax: 0-000-000-0000 OR Maine Bureau of Insurance 00 Xxxxx Xxxxx Xxxxxxx Xxxxxxx, XX 00000

Disputed Claims Procedure. After If you have followed the General Claims Inquiry procedure and have reason to believe your benefit determination was not in accordance with the Agreement between Northeast Delta Dental and your groupterms of this policy, you have the option of using Northeast Delta Dental’s Disputed Claims Procedure. This may be requested within six (6) months of the date of Northeast Delta Dental’s original Explanation of Benefits. It is recommended We recommend that your written request for a review of your claim be personally delivered or mailed certified mail, return receipt requested, to the Vice PresidentDirector, Professional Relations, Northeast Delta Dental, One Delta DriveXxx Xxxxx Xxxxx, PO Box XX Xxx 0000, Xxxxxxx, Xxx Xxxxxxxxx, 00000-2002, Concord, New Hampshire, 03302-2002 but you . You may also submit your request by standard mail. Your request for a review of your claim should refer to the claim(s) in question, state your name and address, and the reasons you think the denial should be evaluated, and . You may provide any additional materials you wish to present. The Vice PresidentDirector, Professional Relations, or his/her designee, will promptly review your claim. He/her may request additional documents as necessary to make such a review and will promptly review your claimreview. If the claim is wholly or partially DeniedXxxxxx in any respect, you will be furnished with a written notice of the decision within thirty (30) days after receipt of the disputed claim. The written notice will include: 1. The specific reason(s) for denial. 2. The specific reference to the provision of this Agreement upon which the denial is based. If your request for review results in an additional payment, it will be made within fifteen (15) working days of the Vice Presidentresponse from the Director, Professional Relations’ responseRelations or his/her designee. If you do have not receive notice received a written response (within the thirty (30) day perioddays as noted above), and/or disagree with the claim is considered Denied in order that response received, you may proceed to the Disputed Claims Review ProcedureProcedure in Section X. Your claim will remain in a Denied status pending the outcome of the review. If you have any problem securing a review of your claim, contact your group for assistance.you may also contact: Community Health Options Mail Stop 100 Atten: Member Services PO Box 1121 Lewiston, Maine 04243 Telephone: 0-000-000-0000 Fax: 000-000-0000 OR Department of Professional & Financial Regulation Bureau of Insurance #34 State House Station Augusta, ME 04333-0034 000-000-0000 (toll free in Maine) or 000-000-0000 Fax: 000-000-0000 SAMPLE

Disputed Claims Procedure. After If you have followed the General Claims Inquiry procedure and have reason to believe your benefit determination was not in accordance with the Agreement between Northeast Delta Dental and terms of your groupplan, you have the option of using Northeast Delta Dental’s Disputed Claims Procedure. This may be requested within six (6) months of the date of Northeast Delta Dental’s original Explanation of Benefits. It is recommended that your written request for a review of your claim be personally delivered or mailed certified mail, return receipt requested, to the Vice PresidentDirector, Professional Relations, Northeast Delta Dental, One Delta DriveXxx Xxxxx Xxxxx, PO Box XX Xxx 0000, Xxxxxxx, Xxx Xxxxxxxxx, 00000- 2002, Concord, New Hampshire, 03302-2002 but you may also submit your request by standard mail. Your request for a review of your claim should refer to the claim(s) in question, state your name and address, and the reasons you think the denial should be evaluated, and . You may provide any additional materials you wish to present. The Vice PresidentDirector, Professional Relations, or his/her designee, may request additional documents as necessary to make such a review and will promptly review your claim. If the claim is wholly or partially DeniedXxxxxx, you will be furnished with a written notice of the decision within thirty (30) days after receipt of the disputed claim. The written notice will include: 1. The i. the specific reason(s) for denial., and 2ii. The the specific reference to the provision of this Agreement upon which the denial is based. If your request for review results in an additional payment, it will be made within fifteen (15) working days of the Vice Presidentresponse from the Director, Professional Relations’ response, or his/her designee. If you do have not receive notice received a written response within the thirty (30) day period, and/or disagree with the claim is considered Denied in order that response you received, you may proceed to the Disputed Claims Review ProcedureProcedure in Section C below. If you have any problem securing a review of your claim, contact your group for assistance.you may also contact: Community Health Options Mail Stop 100 Attn: Member Services PO Box 1121 Lewiston, ME 04243 Telephone: 0-000-000-0000 (TTY/TDD: 711) Fax: 0-000-000-0000 OR Maine Bureau of Insurance 00 Xxxxx Xxxxx Xxxxxxx Xxxxxxx, XX 00000

Disputed Claims Procedure. After If you have followed the General Claims Inquiry procedure and have reason to believe your benefit determination was not in accordance with the Agreement between Northeast Delta Dental and terms of your groupplan, you have the option of using Northeast Delta Dental’s Disputed Claims Procedure. This may be requested within six (6) months of the date of Northeast Delta Dental’s original Explanation of Benefits. It is recommended that your written request for a review of your claim be personally delivered or mailed certified mail, return receipt requested, to the Vice PresidentDirector, Professional Relations, Northeast Delta Dental, One Delta DriveXxx Xxxxx Xxxxx, PO Box XX Xxx 0000, Xxxxxxx, Xxx Xxxxxxxxx, 00000-2002, Concord, New Hampshire, 03302-2002 but you may also submit your request by standard mail. Your request for a review of your claim should refer to the claim(s) in question, state your name and address, and the reasons you think the denial should be evaluated, and . You may provide any additional materials you wish to present. The Vice PresidentDirector, Professional Relations, or his/her designee, may request additional documents as necessary to make such a review and will promptly review your claim. If the claim is wholly or partially DeniedXxxxxx in any respect, you will be furnished with a written notice of the decision within thirty (30) days after receipt of the disputed claim. The written notice will include: 1. The i. the specific reason(s) for denial., and 2ii. The the specific reference to the provision of this Agreement upon which the denial is based. If your request for review results in an additional payment, it will be made within fifteen (15) working days of the Vice Presidentresponse from the Director, Professional Relations’ response, or his/her designee. If you do have not receive notice received a written response within the thirty (30) day period, and/or disagree with the claim is considered Denied in order that response you received, you may proceed to the Disputed Claims Review ProcedureProcedure in Section C below. If you have any problem securing a review of your claim, contact your group for assistance.you may also contact: