X hits on this document





35 / 60

  • Reference to the Plan provision supporting the decision

  • Reference to any other evidence or documentation supporting the decision

  • Statement indicating the customer’s right to a Tier III review and the procedure to do so

If the resolution of the grievance is not satisfactory to the customer, the customer 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 a customer for reversal of a prior communicated UNICARE decision or non-responsiveness is an appeal and advances to Tier III.

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 customer 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 Customer must cooperate with UNICARE in the investigation ¾ Customer will be notified of UNICARE’s determination within five (5) working days of the completion of the investigation ¾ Customer has specific rights and responsibilities (including rights to information, attend the appeal committee meeting, submit new information, to be represented in person)

¾ Review is being managed by a designated individual and any questions should be directed to this individual (the name and telephone number of the individual is provided to the requester in acknowledgment letter)

UNICARE, in communicating in writing a specific decision to the customer, may include the following information as is necessary or required by applicable state or federal regulation:

  • Statement of the reviewer’s understanding of the reasons for the appeal

  • Qualifications of the responsible professional, including licensure of panel members

  • Reviewer’s decision, i.e., recommendation of review panel

  • UNICARE’s decision and rationale if different from panel’s recommendation



Document info
Document views218
Page views218
Page last viewedWed Jan 18 22:37:39 UTC 2017