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| ENROLLEE COMPLAINT PROCEDURE |
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A complaint means any written or oral dissatisfaction about any aspect of our operation including, but not limited to, dissatisfaction with our administration; procedures; denial, reduction or termination of services for reasons not related to medical necessity; disenrollment decisions or the quality of dental services performed by a Contract Dentist. You may call the Customer Service department at (800) 422-4234 or write:
Quality Management Department
c/o Delta Dental Insurance Company
12898 Towne Center Drive
Mailstop QM 600
Cerritos, California 90703-8579
If you write, you must include
- your name, address, telephone number and identification number (i.e. Social Security number), and,
- the Dentist's name and address.
You may submit this information via our Enrollee Assistance Form. Click here to download the form.
A complaint does not include a misunderstanding or problem of misinformation which can be promptly resolved by supplying correct information to your satisfaction.
We do not make determinations about the medical necessity of dental services and only determine if services are covered Benefits under this Contract. We will provide notification if any dental services are not covered Benefits, stating the specific Contract provision(s).
Within five business days after receipt of an oral or written complaint, the quality management coordinator will send a letter acknowledging the date of receipt of the complaint, a description of our complaint procedures, estimated time frames for resolution of complaints and a request for any necessary information. If the complaint was received orally, the acknowledgement will include a one-page complaint form with instructions to return for prompt resolution of the complaint. Processing of the complaint will generally not begin until we receive the information shown above. However, we will respond to complaints involving Emergency Dental Services within 24 hours after receipt of the complaint.
You may call the Customer Service department at (800) 422-4234 at any time between 7 a.m. and 8 p.m., Central Time, to discuss the complaint. Those complaints requiring professional expertise shall be referred to a licensed dental consultant or the dental director for review. Certain complaints may also require a second opinion for a clinical evaluation of the dental services provided. Second opinions will be provided at another Contract Dentist's facility unless otherwise authorized by ALPHA's dental consultant. We will only pay for a second opinion which we have authorized.
We will resolve a complaint involving Emergency Dental Services within 24 hours after our receipt. Complaints that do not involve Emergency Dental Services will be resolved within 30 calendar days after receipt. We will send you a written report which describes the complaint and our resolution. The report will contain a statement of the specific clinical and/or contractual reasons for the resolution and will advise you of:
- the specialization of any Dentist or other provider consulted,
- a description of our appeal procedure, and
- the time frames for our appeal process and final decision.
In the event you are not satisfied with our resolution of a complaint, you will have the right to appeal the decision before a complaint appeal panel. Within five business days after receipt of a request for an appeal, we will send a letter acknowledging the date of receipt of the request and include a statement of your rights to:
- appear before an appeal panel in person (or through a representative if disabled) in the area where you received the care or at an agreed upon location, or
- write to an appeal panel,
- to present alternative expert testimony,
- to present oral or written information, and
- to question those responsible for the prior resolution.
Our appeal panel is composed of Enrollee representatives, Contract Dentist representatives and ALPHA representatives in equal numbers. Contract Dentists cannot review a case in which they rendered care or a case they reviewed during our complaint or appeal process. The panel will include a Contract Specialty Care Dentist if the quality of specialty care is at issue. Our employees cannot serve as Enrollee members.
No later than five business days before the scheduled meeting of the appeal panel, unless you agree otherwise, we shall provide to you or your designated representative:
- any documentation to be presented to the panel by us,
- the specialization of any providers consulted during the investigation of the appeal, and
- the name and affiliation of each ALPHA representative on the panel.
We will send a written resolution of the appeal within 30 calendar days after receipt of an appeal. Investigation and resolution of appeals involving ongoing Emergency Dental Services will be concluded in accordance with the dental immediacy of the case, but no later than 24 hours after receipt of request for appeal. At your request, we will provide, instead of an appeal panel, a provider who has not previously reviewed the case and who is of the same or similar specialty as ordinarily manages the procedure or treatment under appeal. The provider reviewing the appeal may interview you or your designated representative and will make a decision on the appeal. Initial notice of decision of the appeal may be delivered orally, but will be followed by a written notice of the determination within three days.
Notice of our final decision will include a statement of the specific clinical and/or Contract provision(s) on which the decision was based, and the toll-free telephone number and address of the Texas Department of Insurance.
Any Enrollee, including an Enrollee who has attempted to resolve a complaint through the complaint process described above, may file a complaint with the Texas Department of Insurance at P.O. Box 149091, Austin, Texas 78714-9091. The Department's toll-free telephone number is (800) 252-3439.
The commissioner will investigate a complaint against us to determine our compliance with the insurance laws within 60 days after the Department receives the complaint and all information necessary for the Department to determine compliance. The commissioner may extend the time necessary to complete an investigation in the event any of the following circumstances occur:
- additional information is needed;
- an on-site review is necessary;
- we, the provider, or the complainant do not provide all documentation necessary to complete the investigation; or
- other circumstances beyond the control of the Department occur.
We will not engage in any retaliatory action (including termination or refusal to renew a Contract) against you, or a Dentist (on your behalf) for filing a complaint or appealing a decision. |
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© 2008 Delta Dental |
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