Delta Dental of Illinois - Claims Appeal Procedures

The following are Delta Dental of Illinois' claims appeal procedures as required by changes in the federal law known as the Employee Retirement Income Security Act of 1974, as amended. These changes were effective as of July 1, 2002, for all groups.

We have prepared a summary of these procedures for your convenience, followed by a more detailed description.

If you would like to download these documents, click the following link: Download Forms

THIS IS A SUMMARY OF THE CLAIMS APPEAL PROCEDURES. THE COMPLETE DESCRIPTION OF THESE PROCEDURES IS FURNISHED AUTOMATICALLY, WITHOUT CHARGE, AS A SEPARATE DOCUMENT. PRIOR APPROVAL OF BENEFITS Your group dental plan does not require prior approval of dental services. Nonetheless, if you so choose, your or your treating Dentist may request a predetermination of benefits to obtain advance information on your plan’s possible coverage of services before they are rendered. Payment, however, is limited to the benefits that are covered under your plan and is subject to the deductibles, waiting periods, annual and lifetime coverage limits as well as your plan’s payment policies. HOW YOU CONTEST A CLAIM DENIAL Denial of a Claim for Benefits If you make a claim for benefits under this dental plan and your claim is denied in whole or in part, you will receive written notification within 30 days after your claim is received, unless special circumstances require an extension of time for processing. The decision will be sent on a form entitled “Explanation of Benefits.” Your treating Dentist will also be notified on a form entitled "Explanation of Payment." If additional time is necessary for processing a claim for benefits, Delta Dental of Illinois shall notify you and the treating Dentist of the extension and the reason it is necessary within the original 30 day period. If an extension is needed because either you or your treating Dentist did not submit information necessary to decide the claim, the notice of extension shall specifically describe the required information. You will have 45 days from receipt of the notice within which to provide the specified information. Appealing a Claim Denial If you have questions about the denial of your claim, please contact the Customer Service department of DDIL. Because most questions about benefits can be answered informally, DDIL encourages you first to try resolving any problem by talking with Customer Service. However, you have the right to file an appeal requesting that the Delta Dental of Illinois Reevaluation Committee formally review the claim decision without making an informal inquiry. To appeal a denied claim, you must first request that the DDIL Reevaluation Committee review the decision denying the claim. Your request must be in writing and must be made within 180 days of the date of the initial decision denying your claim for benefits. Your appeal should be addressed as follows: Delta Dental of IllinoisAttention Reevaluation Committee111 Shuman BoulevardNaperville, Illinois 60563 If you have any additional documents, records or other information in support of your appeal or if you want to submit written comments, you have the opportunity to do so. Be sure to include the patient name, subscriber name and subscriber identification number on all documents. You must include all facts and all theories which support your claim for benefits. If you fail to include any theories or facts in your written appeal, they will be deemed waived. In other words, you will lose the right to raise factual arguments and theories which support your claim, if you fail to include them in your written appeal. Upon your request, DDIL will provide you, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits. You will be notified within 60 days of the decision on your request for the DDIL Reevaluation Committee to review the decision denying the claim. If you do not exhaust the appeal procedures described above, and if you file a lawsuit for benefits, the court may not permit you to go forward with your lawsuit because you failed to utilize the Plan’s appeal procedures. SPECIAL PROVISIONS APPLICABLE TO DELTACARE DENTAL HMO PROGRAMS: Except as provided below, claims and appeals filed under DeltaCare programs shall follow the same procedures described above. Pre-Service Claims (Specialty Referrals) If your Panel Dentist requests a specialty referral requiring pre-authorization by the DeltaCare Administrator, you and the referring Panel Dentist will be notified by the DeltaCare Administrator of its decision not later than 15 days after the request was made, unless special circumstances require an extension of time. If additional time is necessary because of circumstances beyond the control of the plan, the DeltaCare Administrator shall notify you and the Panel Dentist within the initial 15‑day period. In that notice, you and the Panel Dentist will be advised of the special circumstances requiring an extension of time and the date by which the DeltaCare Administrator expects to issues its decision. If an extension is needed because the referring Panel Dentist did not submit information necessary for a decision, the notice of extension shall specifically describe the required information. The Panel Dentist will have 45 days from receipt of the notice within which to provide the specified information. In the event a specialty referral request requiring pre-authorization is denied, you or the Panel Dentist may appeal this decision within 180 days following receipt of the denial notice. The appeal must be in writing and addressed as follows: DeltaCare Administrator111 Shuman BoulevardNaperville, Illinois 60563 The DeltaCare Administrator will notify the claimant in writing of its decision within 30 days of receipt of the request for review. Urgent Care Claims (Emergency Referrals) If a Panel Dentist makes a request for an emergency referral, the DeltaCare Administrator shall notify you and the Panel Dentist of its decision as soon as possible but not later than 72 hours after receipt of the referral request. If the Panel Dentist fails to provide sufficient information to decide the claim, the DeltaCare Administrator shall notify the Panel Dentist, no later than 24 hours after receipt of the request, of the specific information required. If an expedited review of a benefit denial involving urgent care is necessary, you or the Panel Dentist may request a review via telephone, facsimile or other similarly expeditious method. The DeltaCare Administrator will notify you and the Panel Dentist of its decision no later than 72 hours after receipt of the request for review.