UNICARE will close the grievance file if requested information is not received within ten (10) working days after the 30 day period and will notify the insured of closure due to failure to respond.
If additional time is needed to complete the investigation, UNICARE will contact the insured and other parties as deemed appropriate by Dental Services and inform them of the reason the additional time is required.
Once the grievance review has been completed, UNICARE will communicate in writing the review determination and supporting information to the insured (and other parties as deemed appropriate by Dental Services). Such communication may include the following information as is appropriate and/or required by regulatory entities:
Statement of the reviewer’s understanding of the reason for the grievance
Qualifications of the responsible professional
Reference to the Plan provision supporting the decision
Reference to any other evidence or documentation supporting the decision
Statement indicating the insured’s right to a Tier III review and the procedure to do so
If the resolution of the grievance is not satisfactory to the insured, the insured will be informed of the right to appeal the grievance decision to Tier III, the third level of review.
All information related to the grievance will be maintained for a period of seven (7) years.
A written request by an insured for reversal of a prior communicated UNICARE decision or non-responsiveness is an appeal and advances to Tier III.
A Tier III appeal will be submitted to an appeal panel. The appeal panel may consist of persons not previously involved with the matter, persons not employed by UNICARE and who do not have a financial interest in the appeal.
Upon receipt of an appeal, UNICARE will:
Date stamp the letter and log the appeal in the appropriate system
Assign an individual to manage the appeal
Acknowledge receipt of an appeal in writing within applicable state regulatory requirements to the insured and other parties deemed appropriate by Dental Services
Notify the member within applicable state regulatory requirements of the appeal committee meeting
Advise appropriate individuals that the: ¾ Investigation of the appeal should be completed within sixty (60) working days ¾ Insured must cooperate with UNICARE in the investigation ¾ Insured will be notified of UNICARE’s determination within five (5) working days of the completion of the investigation