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An inquiry not resolved to the customer’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.

Tier II

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 customer 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 Customer must cooperate with UNICARE in the investigation ¾ Customer 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 customer via telephone or in writing if additional information is required in order to process the grievance. Such contact will include providing the customer with the necessary form(s) and/or instructions for obtaining the additional information (e.g. an authorization for release of information form).

If the customer 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 customer that the requested information has to provided or the grievance will be closed.

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 customer of closure due to failure to respond.

If additional time is needed to complete the investigation, UNICARE will contact the customer 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 customer (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

  • Reviewer’s decision

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