DELTA DENTAL PREMIER® AND DELTA DENTAL PPOSM ENROLLEE GRIEVANCE FORM

     
 

Thank you for contacting us regarding your grievance. Your concerns are important to us. Please fill out this form as completely as possible to help expedite our investigation. We protect the privacy of sensitive information such as social security numbers. For more information, see our Web privacy notice.

 
 
Enrollee and Patient Information
       
Enrollee*
First Name
Patient
First Name
Enrollee Last Name Patient Last Name
Enrollee ID Patient Date of Birth / / (mm/dd/yyyy)
Enrollee Date of Birth / / (mm/dd/yyyy) Patient
Phone Number
( ) -
       

Note: If you are submitting a grievance on behalf of a dependent age 18 or older, federal HIPAA regulations require us to obtain signed authorization from that dependent in order to release his or her personal health information.

*Any group member, employee or individual who is eligible to enroll for benefits in accordance with the plan's conditions of eligibility.
       
Street Address    
City    
State    
ZIP Code -    
       
Nature of Grievance
Please describe the nature of your complaint (include dates and names of persons involved).
       
Is this complaint about a dental provider? Yes No    
Dental Provider Name    
Dental Provider City Dental Provider
Phone Number
( ) -
       
Additional Information
When was treatment provided?
(if applicable)
/ / (mm/dd/yyyy) Was it completed? Yes No
Have you discussed your grievance with the dental provider, the provider's staff or anyone at Delta Dental? Yes No
If an agreeable solution can be reached, would you return to the treating dental provider? Yes No
Email address    
Note: A copy of this grievance form may be forwarded to the treating dental provider.
       
If you prefer to mail or telephone your grievance, contact us at:

Delta Dental of California
PO Box 997330
Sacramento, CA 95899-7330

Toll-free number
888-335-8227

       
The law requires the following be placed on all plan grievance forms:

You will receive written confirmation of your grievance within 5 days. You will receive a written decision on your request for review within 30 days (or 60 days if your group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA)), or you will be informed of the pending status of your grievance if more information or time is needed to resolve the matter.

If you have completed Delta Dental's grievance process or if you have been involved in Delta Dental's grievance process for 30 days, you may file a grievance with the California Department of Managed Health Care if Delta Dental has not satisfactorily resolved your grievance. You may immediately file a grievance with the Department in an emergency situation which is one involving severe pain and imminent and serious threat to your health.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 888-335-8227 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888-HMO-2219) and a TDD line (877-688-9891) for the hearing and speech impaired. The department’s Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online.

If your health plan is covered under ERISA, you may also contact the Employee Benefits Security Administration for further review of the claim or if you have questions about your rights under ERISA. The address is Employee Benefits Security Administration, 200 Constitution Avenue, N.W., Washington, DC 20210.

       
   
 
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