The United States Department of Labor has adopted regulations governing claim adjudication and appeals for group health plans governed by ERISA. The new claims and appeals procedures apply to all ERISA plans, whether insured ("risk") or self-funded ("ASO" or "ASC").
Below is the Delta Dental of New Jersey (Delta Dental) Benefit Determination and Appeal Process. The procedures apply to ERISA plans. Delta Dental is currently voluntarily applying these procedures to non-ERISA plans whenever feasible.
This process applies to all ERISA plans for which Delta Dental provides coverage or administration. Delta Dental has also elected to apply this process to non-ERISA plans for which Delta Dental provides coverage on a risk basis.
Predetermination of Benefits
This group dental plan does not require prior approval of dental services. Nonetheless, a Covered Individual and his/her treating Dentist may request a predetermination of benefits to obtain advance information on the plan's possible coverage of services before they are rendered. Payment, however, is limited to the benefits that are covered under this plan as of the date service is rendered and is subject to any applicable deductible, waiting periods, annual and lifetime coverage limits as well as this plan's payment policies.
Notice of Adverse Benefit
If a claim is denied in whole or in part, Delta Dental shall notify the Member and the treating Dentist of the denial in writing, by issuing an Explanation of Benefits (sometimes referred to as an Adverse Benefit Determination), within 30 days after the claim is filed, unless special circumstances require an extension of time, not exceeding 15 days, for processing. If an extension is necessary, Delta Dental shall notify the Member and the Dentist of the extension and the reason it is necessary within the original 30-day period. If an extension is taken because either the Member or the Dentist did not submit information necessary to decide the claim, the notice of extension shall specifically describe the required information and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information.
Explanation of Benefits Form
This form includes the following information:
Request for Informal Review
If the Member or the billing Dentist disagrees with Delta Dental's Adverse Benefit Determination, either may within sixty (60) days of the mailing date of the Adverse Benefit Determination deliver a request to Delta Dental for informal review of the Adverse Benefit Determination. The procedure is explained on the reverse side of the Explanation of Benefits form. Delta Dental will issue its decision on the Informal Review within 60 days after its request of the Informal Appeal. Members are not required to request informal review. Any appeal relating to the original decision or the Informal Appeals decision must be made within 240 days following the mailing date of the original Adverse Benefit Decision.
Request for Appeal of Adverse
If the Member disagrees with Delta Dental's Adverse Benefit Determination, he/she may appeal this determination to Delta Dental within 240 days following the mailing date of the Adverse Benefit Determination. The appeal must be in writing and must state why it is believed that Delta Dental's benefit decision was incorrect. The denial notice, as well as any other documents or information bearing on the claim, should accompany the appeal request. Delta Dental's review of the claim upon appeal will take into account all comments, documents, records or other information submitted by the claimant, regardless of whether such information was submitted or considered in the initial benefit determination.
Delta Dental's Review
The review shall be conducted by a person who is neither the individual who made the initial claim denial nor the subordinate of such individual. If the review is of an Adverse Benefit Determination based in whole or in part on a determination related to dental necessity, experimental treatment or a clinical judgment in applying the terms of the contract, Delta Dental shall consult with a dentist who has appropriate training and experience in the pertinent field of dentistry and who is neither the person who made the initial claim denial nor the subordinate of such individual. Delta Dental shall provide upon request by the claimant the name of any dental consultant whose advice was obtained in connection with the claim denial, whether or not that advice was relied upon in making the initial benefit determination.
Notice of Review Decision
Delta Dental shall notify the claimant in writing of its decision on the Formal Appeal within 30 days of its receipt of the appeal, unless it determines that special circumstances require an extension of time for processing as detailed below. In such cases, written notice of the extension shall be furnished to the claimant prior to the end of the initial 30-day period. In no event shall such extension exceed a period of 60 days from the end of the initial 30-day period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which Delta Dental expects to render the determination on the appeal.
If Delta Dental upholds the Adverse Benefit Determination on appeal, the notice to the claimant shall include the following information:
Special Provisions Applicable
to DeltaCare® Programs
Except as provided below, claims and appeals filed under DeltaCare programs shall be handled in accordance with the procedures set forth above in the sections entitled Notice of Adverse Benefit Determination and Request for Appeal of Adverse Benefit Determination.
Pre-Service Claims (Specialty
In the case of a request for specialty referral requiring pre-authorization by the DeltaCare Plan Administrator, the Plan Administrator shall notify the referring Panel Dentist and the Member of its benefit determination, whether adverse or not, within a reasonable period of time appropriate to the circumstances, but not later than 15 days after the referral request is filed. This period may be extended one time by the plan for up to 15 days if necessary due to matters beyond the control of the plan. If an extension is taken, the Plan Administrator shall notify the Panel Dentist and the Member within the original 15-day period, of the circumstances requiring the extension and the date by which the plan expects to render a decision. If an extension is needed because the Member and/or the Panel Dentist did not submit information necessary to decide the claim, the notice of extension shall specifically describe the required information. The Member and/or Panel Dentist shall be afforded at least 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, the Panel Dentist or the Subscriber may appeal this determination in writing to the DeltaCare Plan Administrator within 240 days following the mailing date of the denial notice. The Plan Administrator shall notify the claimant in writing of its determination on review within 30 days of receipt of the request for review.
Urgent Care Claims (Emergency
In the case of a request for emergency referral, the DeltaCare Plan Administrator shall notify the Panel Dentist and the Member of its benefit determination, whether adverse or not, as soon as possible, but not later than 72 hours after receipt of the referral request. The notice shall include a description of the expedited review and appeal process applicable to urgent care claims. If the Panel Dentist fails to provide sufficient information to decide the claim, DeltaCare shall notify the Panel Dentist and the Member of the specific information required to make a determination on the claim as soon as possible, but not later than 24 hours after receipt of the claim. DeltaCare then shall notify the Panel Dentist and the Member of its determination as soon as possible, but not later than 48 hours after the earlier of (a) the plan's receipt of the specified information or (b) the end of the period afforded the Panel Dentist to provide the additional information.
If an expedited review of a claim denial involving urgent care is necessary, a request for such review may be submitted orally or in writing by the Member or by the Panel Dentist by telephone, facsimile or other similarly expeditious method. The DeltaCare Plan Administrator shall notify the claimant of the determination on review as soon as possible, but not later than 72 hours after receipt of the request for review.
**For the full version of the appeals process, please contact Delta Dental.
Submit questions to:
Delta Dental of New Jersey, Inc.
1639 Route 10
Parsippany, NJ 07054