The following definitions apply to the Inquiry and Appeal Procedure.
"Appeal" means a protest filed by an Enrollee or a health care provider with the Administrator under its internal Appeal process regarding a Coverage Decision concerning an Enrollee.
"Appeal Decision" means a final determination by the Administrator that arises from an Appeal filed with the Administrator under its Appeal process regarding a Coverage Decision concerning an Enrollee.
"Coverage Decision" means an initial determination by the Administrator that results in non-coverage of a health care service.
"Urgent Medical Condition" means a condition that satisfies either of the following:
- A medical condition, including a physical condition, a mental condition, or a dental condition, where the absence of medical attention within 72 hours could reasonably be expected by an individual, acting on behalf of a carrier, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, to result in:
- Placing the member's life or health in serious jeopardy;
- The inability of the member to regain maximum function;
- Serious impairment to bodily function;
- Serious dysfunction of any bodily organ or part; or
- The member remaining seriously mentally ill with symptoms that cause the member to be a danger to self or others; or
- A medical condition, including a physical condition, a mental health condition, or a dental condition, where the absence of medical attention within 72 hours in the opinion of a health care provider with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage decision.
We rely upon the professional judgment of our Contract Dentists to determine the appropriate treatment required for a patient, and we will make Coverage Decisions by reviewing claims to determine whether the rendered services are covered under the terms of this Contract. We will notify you of our Coverage Decisions within 30 calendar days after the Coverage Decision has been made. Notice of the Coverage Decision will include the following information: the reason for the decision; information on how to Appeal the Coverage Decision; a statement that you, or the Dentist acting on your behalf, may file a complaint with the Maryland Insurance Commissioner without first filing an Appeal if the Coverage Decision involves an urgent medical condition for which care has not been rendered; the address, telephone number and facsimile number of the Maryland Insurance Commissioner; a statement explaining that the Health Advocacy Unit is available to assist the Enrollee in both mediating and filing an Appeal under the Administrator's Inquiry and Appeal Procedure; and the address, telephone number, facsimile number and email address of the Health Advocacy Unit.
You may request a second opinion if you disagree with or question the Contract Dentist's diagnosis and/or proposed treatment plan. We may also request that you obtain a second opinion to verify the appropriate application of Benefits. Second opinions will be provided at another Contract Dentist facility, unless otherwise authorized by our dental consultant. You may call the Customer Service department at 800-422 4234 to request a second opinion.
We will provide notification if any claims for dental services are not covered Benefits, stating the specific contractual reason or reasons for the determination. If you, or your Dentist acting on your behalf, have any questions or concerns regarding the determination of eligibility, or our policies, procedures or operations, you may call the Customer Service department at 800-422 4234. If you want to appeal our Coverage Decision or complain about the quality of dental services performed by a Contract Dentist, you may call 800-422 4234 or write the quality management department at:
Delta Dental Insurance Company
12898 Towne Center Drive
Cerritos, California 90703-8579
Written Appeals must include
Within five business days of the receipt of any Appeal, a quality management coordinator will forward to you an acknowledgement of receipt of the Appeal. We will make a determination, in writing, within 30 days of receipt of an Appeal or shall provide a written explanation if additional time is required to report on the Appeal. A final decision will always be made within 60 business days.
The written Appeal Decision will include
- the name of the patient
- the name, address, telephone number and identification number of the Primary Enrollee, and
- the Dentist's name and address.
If a complaint is filed with the Maryland Insurance Commissioner, it must be filed within 60 working days after the date of receipt of the determination. You must exhaust our appeal procedure before filing with the Maryland Insurance Commissioner regarding the coverage decision. However, if your complaint concerns any of the following, you do not need to exhaust the appeal procedure before contacting the Maryland Insurance Commissioner: urgent medical condition for which care has not been rendered, concern regarding the quality of care received, the determination of eligibility or our policies and procedures.
The Maryland Insurance Commissioner may be contacted at:
Maryland Insurance Administration
- a statement of the specific factual basis and/or Contract provision used to make the Appeal Decision;
- the address, telephone number and facsimile of the Maryland Insurance Commissioner; and
- a statement that you, or the Dentist acting on your behalf, have the right to file a complaint with the Maryland Insurance Commissioner within 60 working days after receipt of the Appeal determination.
Attention: Life/Health Complaint Unit
525 Saint Paul Place
Baltimore, Maryland 21202-2272
410- 468-2260 Fax
Complaints to the Maryland Insurance Administration must be in writing. Include your name, address, daytime and evening telephone numbers, as well as the reason for your complaint and copies of any materials that are important to your complaint.