Standard Appeal Process. We will determine if a Member’s 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. The Member is encouraged to provide UCD with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals should be submitted to: United Concordia Dental Appeals Division P.O. Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000 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 Appeals If a Member is 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 administrative Appeals. Requests submitted to UCD after one hundred eighty (180) days of receipt the initial Adverse Benefit Determination will not be considered. UCD will investigate the Member’s concerns. If the administrative Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, UCD will inform the Member of the right to begin the second level administrative Appeal process. The administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals If a Member still di...
Standard Appeal Process. We will determine if a Member’s Appeal is an administrative Appeal or a medical 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 Medical Appeal. The Member is encouraged to provide Us with all available information to help Us completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. We will provide reasonable access to and copies of all documents, records, and other information relevant to the Adverse Benefit Determination.
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.
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. 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. Dental Necessity Appeals
Standard Appeal Process. Xxxxx Vision will determine if a Member’s Appeal as either an administrative Appeal or a Medical Appeal. The Member is encouraged to provide Xxxxx Vision with all available information to help completely evaluate the Appeal such as written comments, documents, records, and other information relating to the Adverse Determination. We will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to his Adverse Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals including administrative Appeals and Medical Necessity Appeals should be submitted in writing to: P. O. Box 791 Latham, NY 12110
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. A committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will meet and review the second level administrative Appeal. The committee’s decision is final and binding. 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.
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. 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.
Standard Appeal Process. We will determine a Member’s Appeal as either an administrative Appeal or a Dental Necessity Appeal. The Member is encouraged to provide UCD with all available information to help completely evaluate the Appeal, such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. UCD will provide the Member, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Adverse Benefit Determination. The Member has the right to appoint an authorized representative to represent him in his Appeals. An authorized representative is a person to whom the Member has given written consent to represent him in a review of an Adverse Benefit Determination. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing. All Appeals including administrative, Dental Necessity and Expedited should be submitted in writing to: United Concordia Dental Appeals Division P.O. Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000
1. Administrative Appeals
Standard Appeal Process. We will distinguish a Member’s Appeal as either an administrative Appeal or a Dental Necessity Appeal.
1. Administrative Appeals Administrative Appeals involve contractual issues other than Dental Necessity denials such as Adverse Benefit Determinations based on the Benefit Plan limitations or exclusions.
Standard Appeal Process. We will determine if a Member’s Appeal is an administrative Appeal or a Dental Necessity Appeal. Administrative Appeals Administrative Appeals involve contractual issues other than Dental Necessity denials such as Adverse Benefit Determinations based on the Benefit Plan limitations or exclusions. First Level Administrative Appeals If a Member is 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 Administrative 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 the Member’s concerns. If the Administrative Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Administrative Appeal is upheld, UCD will inform the Member of the right to begin the second level Administrative Appeal process. The Administrative Appeal decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of receipt of the Member’s request; unless it is mutually agreed that an extension of time is warranted. Second Level Administrative Appeals After review of the first level appeal decision, if a Member is still dissatisfied, a written request to Appeal must be submitted within sixty (60) days of the first level Administrative Appeal decision. Requests submitted to UCD after sixty (60) days of the first level Administrative Appeal decision will not be considered. The committee’s decision will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days of the committee meeting.
