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External Review

If the complaint is concerning an adverse determination as defined above, the insured has a right to request an independent external review. The insured must complete an application along with a $25 filing fee and submit the request to the address shown below.

Upon receiving a request for an external review, the external review entity will request information from both the insured and the insurer in order to complete their review. This information must be provided within 10 days following the request.

To request an independent external review, the insured or their representative should contact:

External Appeals Process State of Minnesota Department of Commerce 133 East 7th Street St. Paul, Minnesota 55101 1-800-657-3602 or 651-296-2488

Claim Administration provided by: WellPoint Dental Services, a division of UNICARE Life & Health Insurance Company.

48657MN

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