COMPLAINT
PROCEDURE, CLAIMS APPEAL AND ARBITRATION
If
you have a complaint regarding the denial of dental services or claims, the
policies, procedures and operation of Delta, you may contact Delta at the
address shown below or by calling toll-free 1-888-335-8227. You have 60 days to
appeal after you receive a notice of denial. (Any questions of ineligibility
should be handled directly between you and your group.) If you write to Delta,
you must include the name of the eligible employee and his/her social security
number (or identification number), the group name and number, the name of the
patient and your telephone number. You should also include a copy of the
treatment form, Notice of Payment and any other information. Clearly explain
your complaint.
You
will receive written confirmation of your complaint within 20 days. You will
receive a written decision on your request for review or a pending letter within
30 days unless more information is needed to resolve the matter. If a referral
to a dental consultant or review committee is required or other unusual
circumstances arise, a decision may take longer but in no event later than 120
days after Delta receives your request.
If
you have completed Delta's grievance process or if you have been involved in
Delta's grievance process for 60 days, you may file a complaint with the
California Department of Corporations if Delta has not satisfactorily resolved
your grievance. You may immediately file a complaint with the Department in an
emergency situation involving imminent and serious threat to your health.
The
California Department of Corporations is responsible for regulating health care
service plans. The Department's Health Plan Division has a toll-free number
(1-800-400-0815) to receive complaints regarding health plans. The hearing and
speech impaired may use California Relay Service's toll-free telephone numbers
[1-800-735-2929 (TTY) or 1-888-877-5378 (TTY) to contact the Department. The
Department's Internet web site (http://www.corlp.ca.gov) has complaint forms and
instructions online. If you have a grievance against your health plan, you
should first telephone your plan at 1-888-335-8227 and use the plan's grievance
process before contacting the Health Plan Division. If you need help with a
grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your plan, or a grievance that has remained unresolved for more than
60 days, you may call the Health Plan Division for assistance. The plan's
grievance process and the Health Plan Division's complaint review process are in
addition to any other dispute resolution procedures available to you, and your
failure to use these processes does not preclude your use of any other remedy
provided by law.
Any
dispute which cannot be settled by these procedures is subject to arbitration in
accordance with the
Commercial
Arbitration Rules of the American Arbitration Association in Los Angeles or Son
Francisco. Arbitration must be initiated by written demand upon each other party
to the dispute as provided in your Evidence of Coverage.
DELTA
DENTAL PLAN OF CALIFORNIA Customer & Member Service Department P.O. Box 7736
San Francisco, CA 94120 Toll-free: 1-888-DELTA CS 1-888-335-8227