DISPUTED CLAIMS

DISPUTED CLAIMS PROCEDURE

Before following Delta Dental’s disputed claims procedure, you or your dentist should first resubmit the claim as an ‘inquiry’ to confirm that Delta Dental’s determination was correct and that all supporting documentation was submitted. Please note that contractual exclusions and limitations cannot be altered. If the claim is still denied, you can follow this disputed claims procedure.

Your disputed claim for benefits under this Plan must be written and mailed certified mail, return receipt requested, to:

Dental Director
Delta Dental Plan of Michigan, Inc.
P.O. Box 30416
Lansing, Michigan 48909-7916.

Your written statement must indicate the patient’s name and address, your Social Security number, the specific basis for your claim and any additional materials you wish to present. The Dental Director or designee will review your statement and, if the claim is wholly or partially denied, will furnish you with a notice of the decision within 90 days of receiving the statement. The written notice will set forth:

1. The specific reason or reasons for denial;

2. The specific reference to the pertinent plan provisions on which the denial is based;

3. If applicable, a description of any further material or information necessary for you to provide and an explanation of why the material or information is necessary; and

4. A copy of the disputed claims appeal procedure.

You will be informed whether or not the appeal has been denied within the 90-day period.

DISPUTED CLAIMS APPEAL PROCEDURE

After following the disputed claims procedure, you or your authorized representative may appeal to the Administrative Committee of Delta Dental by filing a written request for review. Mail your written request to:

Administrative Committee
Delta Dental Plan of Michigan, Inc.
P.O. Box 30416
Lansing, Michigan 48909-7916

Your written request must state specifically the reasons for requesting a review and why you believe the Dental Director’s decision was incorrect.

The Administrative Committee will render its decision not later than 60 days after receiving the written request for review.

If you have any problem securing a review of your claim, contact the Civil Service Group Insurance Section, P.O. Box 30026, Lansing, Michigan, 48909. Decisions made by Delta Dental can be appealed to the Civil Service Group Employee Benefits Division at the above address.