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Applicability and Effective
Date. These Rules apply only to dentists who participate with Delta Dental of New Jersey, Inc. (“Participating Dentists”). They apply only to “claims” determinations. As used in these Rules, “claims” mean requests by covered persons or Participating Dentists for payment relating to dental services or supplies covered under a dental plan issued by Delta Dental of New Jersey, Inc. (“Delta Dental”). “Claims” do not include actions taken by Delta Dental to request or obtain recoupment of payments Delta Dental had previously made to Participating Dentists and/or covered persons; such actions are not subject to these Rules. These Rules are effective October 1, 2008 or ten days following the Participating Dentist’s receipt of these Rules, whichever is later. Any revision of these Rules is subject to the prior approval of the New Jersey Department of Banking and
Insurance.
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Informal Requests for Re-Review
of Claims Determinations (at the option
of the Participating Dentist)
A. Participating Dentists have the option to request that Delta Dental re-review its initial claim determination prior to filing an internal appeal pursuant to Rule 3. Any request for re-review shall be in writing, shall either be mailed to Delta Dental at P.O. Box 222, Parsippany, New Jersey, Attention “Director of Customer Service -- Request for Review” or faxed to Delta Dental at (973) 285-4141 with a cover form addressed to “Request for Re-Review” within thirty (30) days following the Participating Dentist’s receipt of the claim determination for which informal review is requested. The Participating Dentist may supplement his or her initial claim submission with information or documentation pertinent to the claim which had not previously been provided to Delta Dental. Delta Dental will inform the Participating Dentist within fifteen business days of Delta Dental’s decision on informal re-review.
B. Participating Dentists who request re-review of a claim pursuant to Rule 2.A. have the right to file an internal appeal pursuant to Rule 3 if they are not satisfied with Delta Dental’s decision on re-review.
C. Participating
Dentists incur no fee for the informal request for review. Participating Dentists need not complete or submit any particular form to Delta Dental for re-review.
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Internal Appeals
A. Participating
Dentists have the right to file an internal appeal from claim determinations by Delta Dental in accordance with this rule whether or not the Participating Dentist has elected to informally request re-review of the claim as per Rule No. 2.
B.
Each internal appeal must be mailed to Delta Dental, 1639 Route 10, Third Floor, Parsippany, New Jersey 07054 to the attention of “Internal Appeals Program Coordinator” within thirty (30) days of the Participating Dentist’s receipt of the (i) claim determination or (ii) Delta Dental’s decision on re-review as per Rule No. 2, whichever is later. The Participating Dentist must complete and submit the internal appeal form attached to these Rules as Form 1A. A separate form must be submitted for each claim for which internal review is requested.
C. Delta Dental
will reject internal appeals which are not timely mailed as required by Rule 3.B. and notify the Participating Dentist in writing of the reason for the rejection of the appeal.
D. Delta Dental
will resolve all internal appeals which were timely and properly submitted in accordance with Rule 3.B. and will do so within ten (10) business days of Delta Dental’s receipt thereof. However, if the internal appeal is timely filed but the appeal form does not contain all of the required information and/or documentation, Delta Dental will within ten (10) days of its receipt thereof, notify the Participating Dentist in writing (by fax if Delta Dental knows the Participating Dentist’s facsimile number) of the information and/or documentation which was missing and provide the Participating Dentist thirty (30) days within which to cure the deficiency. If the Participating Dentist cures the deficiency, Delta Dental will resolve the internal appeal within ten (10) business days of Delta Dental’s receipt of the missing information and/or documentation. If a Participating Dentist fails to cure the deficiency within the time period set forth in rule 3.B. the internal appeal will be deemed to have been withdrawn by the Participating Dentist.
E. Internal appeals shall be
handled at no cost to the Participating Dentist.
F. Internal appeals shall be
reviewed and resolved by one or more employees
of or consultants retained by Delta Dental
who are not responsible for making claims determinations
on a day-to-day basis.
G. Delta Dental will mail its
determination of each internal appeal to the
address provided by the Participating Dentist
in its internal appeal request. Each such determination
shall be in writing and contain the following
information:
(i)
the name(s), title(s) and qualifying credentials
of the person(s) participating in the internal
review;
(ii)
a statement of the Participating Dentist's
grievance;
(iii)
the reviewer's decision, including a detailed
explanation of the contractual and/or dental
basis for the decision;
(iv)
a description of the information and/or documentation
which supports the decision;
(v)
if adverse, a description of the method to
obtain an external review of the decision.
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External Appeals
A. Participating Dentists have
the right to seek external review of adverse
decisions issued pursuant to Rule 3 hereof.
B. The Participating Dentist
must complete and submit the external appeal
form attached to these Rules as Form 1B for
each internal appeal decision for which external
review is requested, together with $375 as
the Participating Dentist's share of the $750
filing fee and $100 as the Participating
Dentist's share of the $200 AAA case service fee
for claims ranging between $0 and $10,000 for
the external review. In the event a claim
exceeds $10,000, the AAA administrative fee
would be based upon the tiered administrative
fee schedule contained in the then current AAA
commercial arbitration rules and the
Participating Dentist's share would be 50% of
the tiered fee.
C.
The Participating Dentist shall mail the
external appeal documents to Delta Dental,
1639 Route 10, Third Floor, Parsippany, New
Jersey 07054 to the attention of External
Appeals Program Coordinator,
within thirty (30) days of the Participating
Dentist's receipt of the decision issued pursuant
to Rule 3.
D. Delta Dental will reject any
external appeal which was not timely submitted
pursuant to Rule 4.C. and notify the Participating
Dentist of the rejection within thirty (30)
business days of Delta Dental's receipt of
the external review. Delta Dental will notify
the Participating Dentist of any external appeal
which did not contain all of the information
and/or documentation required by Rule 4.B.
If the Participating Dentist fails to cure
the deficiency with thirty (30) days, the external
appeal will be deemed to have been withdrawn
by the Participating Dentist and the filing
fees (if any) will be returned to the Participating
Dentist.
E. All external appeals which
have been submitted and/or revised in conformity
with Rule 4 will be forwarded by Delta Dental
within thirty (30) days to the American Arbitration
Association for non-binding dispute resolution
pursuant to the Expedited Procedures provisions
of the AAA Commercial Arbitration Rules for
a non-binding review by a single arbitrator
at a hearing locale (if any) at the AAA location
closest to Morristown, New Jersey.
F. Delta Dental's submission
pursuant to Rule 4.E. will contain the Participating
Dentist's Form 1B together with a copy of Delta
Dental's Internal and External Rules and Regulations,
a copy of Delta Dental's internal review decision,
and Delta Dental's response to the Participating
Dentist's Form 1B.
G. The AAA arbitrator shall resolve
the dispute without the submission of any additional
information and/or documentation and without
a conference unless the arbitrator determines
in his sole discretion that a conference is
necessary, in which event the arbitrator shall
determine whether to hold the conference in
person or by telephone.
H. The Participating Dentist
and Delta Dental shall have three (3) business
days to strike the names of arbitrators provided
by the AAA, to number the remaining arbitrators
in order of preference and to return the list
to the AAA.
I. In addition to the
filing and service fees which Delta Dental and the Participating
Dentist shall each pay pursuant to Rule 4.B.,
Delta Dental and the Participating Dentist
will bear 50% of the costs of the arbitration.
J. If both the Participating
Dentist and Delta Dental agree in writing within
ten (10) days after the perfection of the appeal
pursuant to Rule 3, they may elect a different
independent external reviewer, a different
appeal procedure, a different allocation of
the appeal costs and/or to make the arbitration
binding (rather than non-binding).
