If UNICARE’s Tier I review determination is not satisfactory to the insured requesting such review, then the associate will inform the insured that to initiate a complaint / grievance, the complaint / grievance request must be in writing. The CSR will provide the insured with the necessary form(s) to be mailed to:
Name: Title: Address:
Barbara Chipres Manager, Compliance UNICARE (Dental Services) 5171 Verdugo Way Camarillo, CA 93012
An inquiry not resolved to the insured’s satisfaction under Tier I and subsequently submitted to UNICARE in writing as a complaint or grievance may advance to the Tier II or Tier III level.
Upon receipt of a grievance, UNICARE will:
Date stamp the letter and log the grievance in the appropriate system
Assign an individual to manage the grievance
Acknowledge receipt of a grievance in writing within applicable state regulatory requirements to the insured and other parties deemed appropriate by Dental Services; and will advise appropriate individuals that the: ¾ Investigation of the grievance should be completed within thirty (30) working days after receipt of the request, unless additional information is required ¾ Insured must cooperate with UNICARE in the investigation ¾ Insured will be notified of UNICARE’s determination in accordance with applicable state regulatory requirements of the completion of the investigation ¾ Review is being managed by a designated individual and any questions should be directed to this individual (provide name and telephone number of the individual to requester in the acknowledgment letter).
UNICARE will contact the insured via telephone or in writing if additional information is required in order to process the grievance. Such contact will include providing the insured with the necessary form(s) and/or instructions for obtaining the additional information (e.g. an authorization for release of information form).
If the insured does not fulfill their responsibilities related to the investigation (e.g., has not provided sufficient requested information, a signed authorization for release of information, etc.) during the thirty (30) day investigation, UNICARE will inform the insured that the requested information has to provided or the grievance will be closed.