Time Limitations for Resolution. The Company will attempt to resolve all Grievances and Benefit determination appeals within 30 calendar days after receipt by the Company. The Company will inform the Subscriber or Covered Dependent of its decision in writing. If the appeal is denied in whole or in part, the notice will include the following information:
(A) The specific reason(s) for the denial of the appeal;
(B) The reference to the specific Contract provision(s) on which the denial is based;
(C) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the claimant’s claim;
(D) A statement describing any voluntary appeal procedures offered by the Company and the claimant’s right to obtain information about such procedures; and a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA;
(E) If an internal processing policy or other similar criterion was relied upon in the denial of the appeal, the notice of such denial also will include either the specific processing policy or a statement that such processing policy was relied upon in denying the appeal and that a copy of that processing policy will be provided free of charge to the claimant upon request;
(F) If the denial of the appeal was based on a dental necessity, experimental treatment or similar exclusion or limit, the notice of such denial also will include an explanation of the scientific or clinical judgment for the determination, applying the terms of the Contract to the claimant’s circumstances, or a statement that such explanation will be provided free of charge upon request; and If the Grievance or Benefit determination appeal cannot be resolved within 30 days from receipt by the Company, the Company will notify the Subscriber, Covered Dependent, or his/her representative, in writing that it intends to extend the period of time for resolution an additional 30 days. The notification will state when resolution may be expected and the reasons for the additional time needed. All Grievances and Benefit Determination appeals will be resolved within 60 days from date of receipt by the Company. The Company’s Grievance Committee shall consist of four persons: a consultant chosen by the Company, a representative of Company management, the Company’s claim administrator, and a Subscriber in a Company plan who is not a Company employee. The Subscriber or Covered Dependent may resolve a...
Time Limitations for Resolution. American Dental Plan of Wisconsin, Inc. will attempt to resolve the Grievance within 30 days after its receipt by American Dental Plan of Wisconsin, Inc. American Dental Plan of Wisconsin, Inc. will inform the Covered Person of its decision in writing identifying the specific reasons for the decision and the specific policy provisions, if any, on which the decision is based. If the Grievance cannot be resolved within thirty (30) days from receipt by American Dental Plan of Wisconsin, Inc., American Dental Plan of Wisconsin, Inc. will notify the Covered Person or the Covered Person's representative in writing that it intends to extend the period of time for resolution an additional thirty (30) days. The notification will state when resolution may be expected and the reasons for the additional time needed. All Grievances will be resolved within 60 days from date of receipt by American Dental Plan of Wisconsin, Inc. American Dental Plan of Wisconsin, Inc.'s Grievance Committee shall consist of three participating dentists, a representative of American Dental Plan of Wisconsin, Inc. management, and, if available, one American Dental Plan of Wisconsin, Inc. participant. You may resolve your problem by taking the steps in American Dental Plan of Wisconsin, Inc.'s grievance procedure outlined above. You may also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by writing to: Complaints Department P.O. Box 7873 Madison, WI 00000-0000 or you can call 0-000-000-0000 outside of Madison or 266-0103 in Madison, and request a complaint form.
