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  • 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 appeal the decision to the Plan Administrator or appropriate state regulator, including the telephone number and address of the commissioner

  • Statement concerning right of customer under ERISA Section 502(a) with respect to civil action

  • Statement indicating the decision is UNICARE’s final determination

UNICARE will contact the customer either by telephone or in writing if additional information is required in order to process the appeal. 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).

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 sixty (60) day investigation, UNICARE will inform the customer that the requested information has to be provided or the appeal will be closed.

UNICARE will close the appeal file if requested information is not received within ten (10) working days after the sixty 60-day period and will notify the customer of closure due to failure to respond.

All information related to the appeal will be internally reviewed by a committee consisting of individuals who were not involved in the decision being appealed.

All information pertaining to the appeal will be filed and maintained for a period of seven (7) years.

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



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