|
|
 |
|
| ENROLLEE COMPLAINT PROCEDURE |
|
| |
Delta Dental will send notice if any dental services or claims are denied, in whole or in part, stating the specific reason(s) for the denial. Any complaint regarding eligibility, the denial of dental services or claims, the policies, procedures or operations of Delta Dental or the quality
of dental services performed by a Contract Dentist or Contract Specialist, may be addressed in writing or by telephone, to:
Quality Management Department
Delta Dental of New York, Inc.
Administrative Offices
1 Delta Drive
Mechanicsburg, PA 17055
800- 234-2334
Written communication must include:
- the name of the patient,
- the name, address, telephone number and identification number of the primary Enrollee and
- the Dentist's name and facility location.
Within 10 business days of the receipt of any complaint, and the above information, a quality management coordinator will send you an acknowledgment of receipt of the complaint. Complaints that require professional expertise will be sent to a licensed dental consultant, or if necessary, the dental director for response. Certain complaints may require that the complainant be referred to a Dentist for a clinical evaluation of the dental services provided. Delta Dental will make a determination, in writing, within 30 days of receipt of a complaint or shall provide a written explanation if additional time is required to report on the complaint. A review of the decision shall be undertaken if a written request for an appeal of the determination is made within 30 days of the date of the written determination. Delta Dental shall undertake a full and fair review upon request. We may require additional documents as deemed necessary in making such a review. Delta Dental shall provide a written response to the complainant within 30 days after receipt of the appeal and supporting documentation or a written explanation if additional time is required to issue the results.
New York Insurance Law gives you the right to request an external appeal when treatment is denied on the basis that services were not medically necessary or were experimental or investigational in nature.
Delta Dental makes coverage decisions rather than determinations of medical necessity. Therefore, this provision has limited application. Because of the nature of dental disease and since dental programs generally cover preventive and basic dental procedures, there are few benefit decisions
that involve a serious threat to your life or health. However, a limited number of dental procedures do require a determination of medical necessity. These procedures are necessary to prevent, or treat, a serious threat to your life or health. Some examples of such procedures are: acute cellulitis resulting from a bacterial infection whose origin is a decayed tooth; or a secondary infection of the oral cavity following the extraction of a tooth.
For complete information regarding Delta Dental's Utilization Review procedures and the External Review process, see APPENDIX A and ATTACHMENT ONE, DELTA DENTAL OF NEW YORK'S INTERNAL GRIEVANCE PROCEDURE rider which are attached to this booklet.
|
| |
| |
| |
|
|
|
HIPAA Notice of Privacy Practices | Web Site Privacy Notice
© 2011 Delta Dental |
|
