Common use of To File a Formal Grievance Clause in Contracts

To File a Formal Grievance. A Grievance is a written expression of dissatisfaction with Us, the Claims Administrator or with a Provider. If the Member does not feel his Complaint was adequately resolved or he wishes to file a formal Grievance, a written request must be submitted within one hundred eighty (180) days of the event that led to the dissatisfaction. UCD Customer Service Department will assist the Member if necessary. The Member should send his written Grievance to: United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 A response will be mailed to the Member within thirty (30) business days after We receive the Member’s written Grievance. UCD offers two (2) levels of Appeal for both administrative Appeals and Dental Necessity Appeals. If a Member is an ERISA Member, the Member is required to complete the first level of Appeal prior to instituting any civil action under ERISA section 502(a). The second level of Appeal is voluntary. Any statute of limitations or other defense based on timeliness is tolled during the time any voluntary Appeal is pending. The Member’s decision whether or not to submit to this voluntary level of review will have no effect on the Member’s rights to any other Benefits under the plan. No fees or costs will be imposed on the Member. The Member may also call UCD if they have questions or needs assistance putting the Appeal in writing. UCD 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 in writing 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 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 If a Member still disagrees 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. 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. 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 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 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 the Member’s concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform the Member 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 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. 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. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees 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 the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your

To File a Formal Grievance. A Grievance is a written expression of dissatisfaction with Us, the Claims Administrator or with a Provider. If the Member does not feel his Complaint was adequately resolved or he wishes to file a formal Grievance, a written request must be submitted within one hundred eighty (180) days of the event that led to the dissatisfaction. UCD Customer Service Department will assist the Member if necessary. The Member should send his written Grievance to: United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 A response will be mailed to the Member within thirty (30) business days after We receive the Member’s written Grievance. UCD offers two (2) levels of Appeal for both administrative Appeals and Dental Necessity Appeals. If a Member is an ERISA Member, the Member is required to complete the first level of Appeal prior to instituting any civil action under ERISA section 502(a). The second level of Appeal is voluntary. Any statute of limitations or other defense based on timeliness is tolled during the time any voluntary Appeal is pending. The Member’s decision whether or not to submit to this voluntary level of review will have no effect on the Member’s rights to any other Benefits under the plan. No fees or costs will be imposed on the Member. The Member should contact his employer, Plan Administrator, Plan Sponsor, or UCD at 0-000-000-0000 if the Member is unsure whether ERISA is applicable. The Member may also call UCD if they have questions or needs assistance putting the Appeal in writing. UCD 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 in writing 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 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 If a Member still disagrees 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 meet and review the second level administrative Appeals. The committee’s decision is final and binding. 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. 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 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 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 the Member’s concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform the Member 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 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. 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. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees 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 the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute youryour 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.

To File a Formal Grievance. A Grievance is a written expression of dissatisfaction with Us, the Claims Administrator or with a Provider. If the Member does not feel his Complaint was adequately resolved or he wishes to file a formal Grievance, a written request must be submitted within one hundred eighty (180) days of the event that led to the dissatisfaction. UCD Customer Service Department will assist the Member if necessary. The Member should send his written Grievance to: United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 A response will be mailed to the Member within thirty (30) business days after We receive the Member’s written Grievance. UCD offers two (2) levels of Appeal for both administrative Appeals and Dental Necessity Appeals. If a Member is an ERISA Member, the Member is required to complete the first level of Appeal prior to instituting any civil action under ERISA section 502(a). The second level of Appeal is voluntary. Any statute of limitations or other defense based on timeliness is tolled during the time any voluntary Appeal is pending. The Member’s decision whether or not to submit to this voluntary level of review will have no effect on the Member’s rights to any other Benefits under the plan. No fees or costs will be imposed on the Member. The Member should contact his employer, Plan Administrator, Plan Sponsor, or UCD at 0-000-000-0000 if the Member is unsure whether ERISA is applicable. The Member may also call UCD if they have questions or needs assistance putting the Appeal in writing. UCD 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 in writing 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 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 If a Member still disagrees 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 meet and review the second level administrative Appeals. The committee’s decision is final and binding. 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. 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 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 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 the Member’s concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform the Member 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 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. 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. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees 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 the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute youryour 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.

To File a Formal Grievance. A Grievance is a written expression of dissatisfaction with Us, the Claims Administrator Us or with a ProviderProvider services. If the Member does not feel his Complaint was adequately resolved or he wishes to file a formal Grievance, a written request must be submitted within one hundred eighty (180) days of the event that led to the dissatisfactiondays. UCD Customer Service Department Xxxxx Vision customer service department will assist the Member if necessary. The Member should send his written Grievance to: United Concordia Dental Customer Service P.O. P. O. Box 69420 Harrisburg791 Latham, PA 17106-9420 NY 12110 A response will be mailed to the Member within thirty (30thirty) 30 business days after We receive of receipt of the Member’s written Grievance. UCD Multiple requests to Appeal the same Claim, service, issue, or date of service will not be considered, at any level of review. Xxxxx Vision offers two (2) levels of Appeal for both administrative Appeals and Dental Medical Necessity Appeals. If a Member is an ERISA Member, the Member is required to complete the first level of Appeal prior to instituting any civil action under ERISA section 502(a). The second level of Appeal is voluntary. Any statute of limitations or other defense based on timeliness is tolled during the time any voluntary Appeal is pending. The Member’s decision whether or not to submit to this voluntary level of review will have no effect on the Member’s rights to any other Benefits under the plan. No fees or costs will be imposed on the Member. The Member may also call UCD should contact his Employer, Plan Administrator, Plan Sponsor, or Our customer service department at 0-000-000-0000 if they have questions or needs assistance putting the Appeal in writingMember is unsure whether ERISA is applicable. UCD Xxxxx Vision will determine if a Member’s Appeal is as either 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 Medical Appeal. The Member is encouraged to provide UCD Xxxxx Vision with all available information to help completely evaluate the Appeal, Appeal such as written comments, documents, records, and other information relating to the Adverse Benefit Determination. UCD 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 the his 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 Appeals and Medical Necessity Appeals should be submitted in writing to: United Concordia Dental Appeals Division P.O. P. O. Box 69420 Harrisburg791 Latham, PA 17106-9420 NY 12110 Administrative Appeals Administrative Appeals involve contractual issues, which are not related to Dental Necessity, appropriateness, healthcare setting, level of care, effectiveness issues other than Medical Necessity such as an Adverse Benefit Determinations based on limitations or treatment is determined to be experimental or investigationalexclusions. 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 Xxxxx Vision after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD Xxxxx Vision will investigate the Member’s concerns. If the administrative Appeal is overturned, UCD Xxxxx Vision will reprocess the Member’s Claim, if any. If the administrative Appeal is upheld, UCD Xxxxx Vision 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 After review of Our first level Appeal decision, if a Member is still disagrees with the first level administrative Appeal decisiondissatisfied, 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 Xxxxx Vision after sixty (60) days of receipt of the first level administrative Appeal decision will not be considered. A Member Appeals Committee of persons not involved in previous decisions regarding the initial Adverse Benefit Determination will review the second level administrative Appeals. The committeeCommittee’s decision is final and binding. 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 Committee meeting. Dental Necessity Appeals Dental Medical Necessity Appeals involve a denial or partial denial based on Dental Medical 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. First Level Internal Dental Medical Necessity 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 Dental Medical Necessity Appeals. Requests submitted to UCD Xxxxx Vision after one hundred eighty (180) days of receipt of the initial Adverse Benefit Determination will not be considered. UCD Xxxxx Vision will investigate the Member’s concerns. If the Dental Medical Necessity Appeal is overturned, UCD Xxxxx Vision will reprocess the Member’s Claim, if any. If the Dental Medical Necessity Appeal is upheld, UCD Xxxxx Vision will inform the Member of the right to begin the External second level Medical Necessity Appeal process if the Adverse Benefit Determination meets the criteriaprocess. The Dental Medical Necessity 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. External Dental Second Level Medical 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. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the a Member still disagrees with the internal Dental first level Medical Necessity Appeal decision or Rescission of Coveragedecision, a written request for an External to Appeal must be submitted within four sixty (460) months of receipt days of the internal Dental first level Medical Necessity Appeal decision or Rescission of Coveragedecision. Requests submitted to Us Xxxxx Vision after four sixty (460) months of receipt days of the internal Dental first level Medical Necessity Appeal decision or Rescission of Coverage will not be considered. You are required to sign the form included The second level Medical Necessity Appeal will be reviewed by a Provider who holds a non-restricted license issued in the internal Dental Necessity Appeal denial notice which authorizes release of medical records for review by United States in the IRO. Appeals submitted by Your Provider will not be accepted without this form completed with Your signature. We will provide same or an appropriate specialty that typically manages the IRO all pertinent information necessary to conduct the Appealcondition, procedure or treatment under review. The external review decision is final and binding. The decision will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf behalf, within thirty (30) days of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute yourreview.

To File a Formal Grievance. A Grievance is a written expression of dissatisfaction with Us, the Claims Administrator or with a Provider. If the Member does not feel his Complaint was adequately resolved or he wishes to file a formal Grievance, a written request must be submitted within one hundred eighty (180) days of the event that led to the dissatisfaction. UCD Customer Service Department will assist the Member if necessary. The Member should send his written Grievance to: United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 A response will be mailed to the Member within thirty (30) business days after We receive the Member’s written Grievance. Multiple requests to Appeal the same Claim, service, issue, or date of service will not be considered, at any level of review. UCD offers two (2) levels of Appeal for both administrative Administrative Appeals and Dental Necessity Appeals. If a Member is an ERISA Member, the Member is required to complete the first level of Appeal prior to instituting any civil action under ERISA section 502(a). The second level of Appeal is voluntary. Any statute of limitations or other defense based on timeliness is tolled during the time any voluntary Appeal is pending. The Member’s decision whether or not to submit to this voluntary level of review will have no effect on the Member’s rights to any other Benefits under the plan. No fees or costs will be imposed on the Member. The Member may also call UCD if they have questions or needs assistance putting the Appeal in writing. UCD 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. The Member may also call UCD if they have questions or needs assistance putting the Appeal 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 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 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 0-000-000-0000 Providers will be mailed to the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf, within thirty (30) days notified 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 disagrees 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. 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. 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 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 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 the Member’s concerns. If the Dental Necessity Appeal is overturned, UCD will reprocess the Member’s Claim, if any. If the Dental Necessity Appeal is upheld, UCD will inform the Member of the right to begin the External Appeal process results only if the Adverse Benefit Determination meets the criteria. The Dental Necessity 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. 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. A Member must exhaust all internal Appeal opportunities prior to requesting an External Appeal conducted by an Independent Review Organization. If the Member still disagrees 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 filed the Appeal. The external review will be completed within forty-five (45) days of receipt of the External Appeal. The IRO will notify the Member, his authorized representative, or a Provider authorized to act on the Member’s behalf of its decision. The IRO decision will be considered a final and binding decision on both the Member and UCD for purposes of determining coverage under a dental Plan. This Appeals process shall constitute your.