|ENROLLEE COMPLAINT PROCEDURE
Delta Dental will address all Enrollee inquiries, complaints and grievances promptly and professionally. Written records will be maintained classifying such Enrollee contacts by type (i.e. inquiry, complaint or grievance) in a written log. Delta Dental will routinely advise Enrollees of their rights under the complaint/grievance system over the telephone and on all claims and other correspondence which refer to benefits which have been denied.
An inquiry is any Enrollee's request for administrative service, or information, or to express an opinion. Whenever specific corrective action is requested by the Enrollee, or determined to be necessary by Delta Dental, it should be classified as a complaint.
A complaint is an issue an Enrollee presents to Delta Dental, either in written or oral form, which is subject to informal resolution by Delta Dental within a 30 day period. A written log of each complaint and its disposition is maintained. Failure to render a decision within the 30 day timeframe automatically results in the complaint being upgraded to a grievance.
A grievance is a complaint which cannot be resolved to the Enrollee's satisfaction or when the Enrollee requests formal grievance consideration during the 30 day period. All grievances shall be committed to written form by either the Enrollee or Delta Dental prior to processing.
Delta Dental shall provide notification if any dental services or claims are denied, in whole or in part, stating the specific reason or reasons for the denial. If an Enrollee has 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, he or she may call the Customer Service department at (800) 422 4234, or the complaint may be addressed in writing to:
Written communication must include
Delta Dental Insurance Company
MS: QM 600
12898 Towne Center Drive
Cerritos, California 90703-8579
A systematic progression of appeals will be in place. If the initial decision is appealed and informal resolution has not been possible, it will be addressed by the 1st Level Grievance Committee. If the 1st Level Grievance Committee's decision is appealed, that appeal will be addressed by the 2nd Level Grievance Committee. If the 2nd Level Grievance Committee's decision is appealed, that appeal will be addressed by the Pennsylvania Department of Health.
At each step, if the decision is not in favor of the Enrollee, the Enrollee will be advised
- the name of the patient,
- the name, address, telephone number and identification number of the primary Enrollee, and
- the Dentists name and facility location.
1st Level Grievance Review Committee
Appeals will first be addressed by the 1st Level Grievance Review Committee. The committee is made up of one or more Delta Dental employees. The committee will not include any person whose decision is being appealed or who made the initial determination denying claim or handling a complaint. This first level review may be in the form of a telephone conference, staff meeting or polling of experts by telephone.
The Enrollee has the right to submit written material and to have an uninvolved staff person assist, but the Enrollee does not have the right to attend or to have representation in attendance at this stage. Delta Dental will advise Enrollees of their rights.
The review will be conducted within 30 days of receipt of the appeal. The decision of the 1st Grievance Review Committee will be made known to the Enrollee in writing at the earliest possible time following the review but not more than five working days after the date of the review.
Written decision will contain:
- of the right to appeal the decision and
- of how to use the appeal process.
2nd Level Grievance Review Committee
Delta Dental's 2nd Level Grievance Committee will be made up of three (3) members. In agreement with the Pennsylvania HMO Act and the Department of Health Regulations, the members will be selected by the Board of Directors and one-third of the members shall be actual Delta Dental Enrollees. A Delta Dental Enrollee will be selected when needed to serve on a Grievance Review Committee. The subscriber member will be selected from among the Delta Dental employer and union groups' benefits administrators who are also Delta Dental Enrollees.
This committee may not include any person previously involved in the grievance. Committee members must have the ability to be fair and impartial. A continuity of the Grievance Committee Membership is necessary so as to facilitate a knowledgeable and consistent approach to grievance resolution. It is imperative that the committee carefully consider and make particular findings of fact on all key factual disputes.
Provisions Regarding Enrollee Rights
- Description of the committee's understanding of Enrollee's grievance as presented to the grievance committee, e.g. dollar amount of the disputed issue, medical facts in dispute, etc.;
- Committee's decision in clear terms and the contract basis or medical rationale in sufficient detail for Enrollee to respond further to Delta Dentals position, e.g. did not contact primary care physician, non-emergency service as identified in dental records, or not covered by group contract;
- Evidence or documentation used as the basis for the decision should be referenced in the letter, e.g. specific provisions, Group contract, dental records, etc.; and
- Statement indicating:
- decision is binding unless the Enrollee appeals to the second level;
- a description of the process on exactly how to appeal to the 2nd Level Grievance Review Committee; and
- the written procedures governing appeal including the required timeframe of 35 days from the date of the letter for appeal.
Provisions Regarding the Hearing Process
- The Enrollee always has a right to attend the 2nd level hearing and to present his case and has the right to be assisted/represented by a person of his choice. The hearing will be held in Pennsylvania or in another location convenient to the Enrollee.
- The Enrollee may again submit written material in support of his claim. Formal rules of evidence are not appropriate, and the Enrollee may arrange for a physician or other expert to testify on his behalf.
- The Enrollee has the right to question Delta Dental staff concerning the dispute.
- The Enrollee's right to a fair and equitable hearing may not be made conditional on his/her appearance at the hearing. Regardless of the Enrollee's presence or lack of, the hearing must be conducted in the same manner.
- Delta Dental is responsible for insuring that hearings are held at mutually convenient times. The Enrollee shall be notified in writing, at least 15 days in advance, of the date and time of the hearing, which should be held within 30 days of receipt of the appeal. Requests for hearing postponement by an Enrollee (for just cause) must be considered.
- The Enrollee shall receive a description of the Committee's procedures so as to permit him/her to be prepared for the hearing.
- The Enrollee should also be re-advised of his/her rights to have a non-involved staff person to assist him/her in preparing for the grievance hearing.
Policy Statement for Recording 2nd Level Grievance Review Committee Proceedings
- The written decision of the 1st Level Grievance Committee shall be the basis for deliberation. The objective is to keep the hearing informal and impartial so as not be intimidating to the Enrollee.
- Matters brought before the Grievance Committee should not be discussed by the Committee prior to the meeting.
- Committee members should be introduced to the Delta Dental Enrollee filing the appeal, and there should be clear identification of the subscriber member and Delta Dental staff serving on the Committee.
- There should be a clear recognition on the part of all members of the Committee, subscriber members and Delta Dental staff alike, that their responsibility is to impartially hear and consider the dispute based solely on the material and presentations made during the hearing.
- If an attorney representing Delta Dental is present at the hearing, the primary purpose of the attorney should be to represent the interest of the impartial Grievance Review Committee in insuring that a fundamentally fair hearing takes place and all issues in dispute are adequately addressed. The attorney should not argue or represent Delta Dental staff position in the dispute.
- If Delta Dental desires to have an attorney present to represent the interests of the Delta Dental staff, it also must make available an attorney to represent and assist the Grievance Committee.
- The 2nd level hearing will be tape recorded. Written summary minutes will be prepared from this tape. A written transcript will be prepared for all hearings involving cases in excess of $5,000.00.
- A member of the Delta Dental staff previously involved in and knowledgeable about the grievance should present and summarize for the Committee, the Delta Dental staff's rationale for recommending that the denial be affirmed by the 2nd Level Grievance Committee.
- The Committee should be permitted to ask questions of the Delta Dental staff.
- The Delta Dental Enrollee or his/her representative should be given the right to present his/her side of the dispute, and ask questions of the Delta Dental person(s) presenting the Delta Dental side of the dispute.
- The Committee must render a decision no more than 10 working days following the Grievance Committee meeting.
- The Enrollee must be advised, in writing, of the outcome of the Committee's deliberation. The written notice shall contain:
- a statement of the Committee's understanding of the nature of the grievance and of all pertinent facts;
- the Committee's decision and rationale;
- evidence or documentation supporting such conclusions; and
- a statement of the Enrollee's right to appeal to the Department of Health with the phone number and complete address of the Department. The address and phone number to be used is:
Bureau of Health Financing and Program Development
Pennsylvania Department of Health
Room 1026 Health & Welfare Building
P. O. Box 90
Harrisburg, PA 17108-0090
Phone: (717) 787-5193
Provisions to Expedite Grievances Where There is Alleged Medical Urgency
Grievances usually deal with claim denials, and the remedy sought is payment of the claim by Delta Dental. In those cases, however, which an Enrollee believes that serious medical consequences will arise in the near future (7 to 10 days) from Delta Dental's failure to provide needed, medically necessary and covered health services, there is a procedure for expedited review.
In such a case, the Enrollee should identify the particular need for an expedited review to the Customer Service department. Delta Dental will arrange to have the grievance reviewed by a dental director within 48 hours and the dental director will inform the Enrollee of their decision in writing.
If the dental director's decision is adverse to the Enrollee, the Enrollee may appeal the decision immediately to the 2nd Level Grievance Review Committee.
The Bureau of Health Financing & Program Development in the Pennsylvania Department of Health, Room 1026, Health & Welfare Building, P.O. Box 90, Harrisburg, PA 17108 0090 (717 787 5193) is responsible for monitoring Delta Dental compliance with the grievance procedures.
- All 2nd level grievance procedure meetings will be tape recorded. Upon request of the Pennsylvania Department of Health, a duplicate tape will be sent to the Department.
- Summary minutes will be used for the purpose of responding to the Enrollee regarding the decision of the 2nd Level Grievance Committee.
- Verbatim transcript will be made of all 2nd Level Grievance Committee meetings involving cases in excess of $5,000.00.
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