The Grievance and Appeal Procedures provide members with formal processes for expressing dissatisfaction concerning quality of care, determination of benefits, authorization of services and claim denials. These procedures were updated for dentists contracted with Dental Network of America (DNoA), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma and Blue Cross and Blue Shield of Texas.
All inquiries and results will be resolved and communicated in a timely manner, depending upon the urgency of the situation and the requirements of specific state laws.
If an inquiry cannot be resolved due to insufficient information necessary for a full investigation, a decision will be rendered based upon available information. If additional information is received at a later date, the grievance will be reopened.
If a member disagrees with the decision regarding their claim, they can submit a written request to appeal the original decision. Upon receipt of an appeal, the case will be forwarded to the appropriate department for further consideration.
1) Grievances (Quality of Care Concerns)
Members may express dissatisfaction with the services of DNoA, its contracted providers or non-contracted providers. For example, a member may express concern about the quality of the care they received or the conditions of a provider’s office. During the investigation of grievance matters, DNoA relies on providers to fully cooperate by supplying records, X-rays, or other treatment documentation so we can respond to grievances fully.
2) Reconsiderations (One-Time Provider Request for Benefit/Payment Review)
Providers can file a reconsideration to request a review of the denial of a service or benefit determination. All reconsideration requests will be resolved and communicated in a timely manner, depending upon the urgency of the situation and the requirements of specific state laws. It is important you provide all relevant documentation needed to support your reconsideration request (i.e., records, X-rays, treatment notes, etc.). In addition, you should include a complete explanation of why you believe a reconsideration of the benefit, authorization of services, or claim denial should be overturned. A decision on an appeal will be in writing and is considered a final determination.
3) Appeals (Formal Member Request for Review)
An appeal is a right afforded to members to request a review of a determination made by DNoA regarding benefits or claims. The member also has the right to be represented by a family member or other party, including a provider. If your patient expressly requests that you represent them in filing an appeal with DNoA on their behalf, you must include a HIPAA Compliant Standard Authorization Form (SAF) with the appeal, along with any documentation in support of the appeal. In the event that a provider and member each file an appeal on the same denied claim, each appeal submission will be handled and responded to separately.
Questions
If you have questions about these procedures, please contact DNoA at (800) 972-7565. DNoA provides administration services on behalf of Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas.