Page 73

Effective Date:

Approval Date: 73

UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Time frame for decision to be made Every attempt will be made to provide a decision for expedited appeals that are emergent in nature within 24 hour turnaround of receipt of complete medical information necessary to render a decision. Within 72 hours of request Every attempt is made to provide a decision as quickly as possible. Notification of decision The Enrollee will be informed of the decision by telephone or fax within 72 hours. In addition, a written decision is issued within 2 business days detailing the decision. If ruling is not in favor of the Enrollee, the Enrollee has 14 days to appeal the decision orally or in writing. By phone or fax, followed by written decision. By phone or fax, followed by a written decision. Second Level Appeal An appeal to Grievance Committee is a further request from an Enrollee than an unfavorable Level 1 complaint decision be reversed. If not satisfied with the resolution of first level appeal, Enrollee may appeal to the Enrollee Appeal Committee of the Board. A second request may be made if not satisfied with appeal decision. Time frame to file a second level appeal If the Enrollee is not satisfied with the outcome of the decision he/she has 14 days from the date the decision was issued in which to file a formal appeal to the Enrollee Grievance Committee of UHC. Must be filed within 30 calendar days of receipt of decision Must be filed within 30 days of receipt of the decision. Decision maker The Grievance Committee. Grievances will not be heard or voted upon unless at least 50% of the voting individuals of the committee are Enrollees who are consumers. The Grievance Committee shall have authority to resolve by majority vote grievances filed by Enrollees. The panel will include participants who were not involved in the previous decisions. A physician who was not previously involved will review the case when it involves a denial of services or treatment based on medical necessity. At least one Enrollee Appeal Committee of the Board Dental director or dental consultant.