| ALPHA 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 ALPHA, 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:
Quality Management Department
12898 Towne Center Drive MS: QM600
Cerritos, California 90703-8579
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 five business days of the receipt of any complaint, a quality management coordinator will forward to the complainant an acknowledgment of receipt of the complaint. Certain complaints may require that the complainant be referred to a Dentist for a clinical evaluation of the dental services provided.
ALPHA 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. ALPHA shall undertake a full and fair review upon any request. ALPHA may require additional documents, as it deems necessary in making such a review. ALPHA 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 decision. |
