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National Dental Grievance, Complaints, Appeals Process

Application: All UNICARE business.

Definitions:

Inquiries* and Complaints* are questions or concerns from insureds regarding any aspect of UNICARE’s operation which may include (but are not limited to):

  • Claims payment, handling or reimbursement for dental care services

  • Matters pertaining to the contractual relationship between an insured and

UNICARE Grievances* are an insured’s dissatisfaction with:

  • The availability, accessibility, or delivery of services by network providers

  • The response to an insured’s concern

Appeals* are requests by insureds for reconsideration of a claim determination or pre-authorization made by UNICARE in accordance with the client’s plan with respect to benefits payable under the plan. Appeals are written requests for a second review.

Adverse Determination is a determination that a health care service has been reviewed and was denied on the basis that the service was not medically necessary.

Insured is an individual or entity (or the authorized representative of an individual or entity) to whom UNICARE provides services. Specifically, this definition of insured includes, but is not limited to, clients, patients, enrollees, dental care providers or provider facilities (or their authorized representative).

Purpose:

To provide a fair and reasonable process for handling inquiries, complaints

grievances and appeals from insureds.

Overview:

The following guidelines are to set forth the UNICARE policy and procedures

for resolution of complaints, grievances and appeals; and are subject to all state and federal laws and specific plan provisions.

UNICARE Dental Services may receive inquiries, complaints, grievances and appeals either by telephone through the Customer Service Unit (CSU) or by mail to the Technical Support Unit (TSU). Dental Services Associates will record all inquiries, complaints, grievances, and appeals in the appropriate tracking system using the appropriate codes. Following are the data elements to be captured for all inquiries, complaints, grievances, and appeals.

*Instances where an inquiry, complaint, grievance, or appeal involves an imminent and serious threat to the health of the patient shall be processed in accordance with UNICARE Dental Services’ Expedited Review Process which complies with applicable regulatory requirements.

48657MN

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