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7.3 Complaints, Grievances, and Appeals. <br />7.3.1 Complaints. <br />a. Enrollees are encouraged to discuss matters regarding service, care, or treatment with <br />the Participating Provider and Participating Provider s staff. Most matters can be <br />resolved with the Participating Provider and Participating Provider's staff. <br />b. If the Enrollee requests a specific service the Participating Provider will use his/her <br />judgment to determine if the service is dentally necessary. The Participating Provider <br />will recommend the most appropriate course of treatment. <br />c. Enrollees may also contact the Member Services Department with questions or <br />complaints at: <br />Willamette Dental of Washington, Inc. <br />Attn: Member Services <br />6950 NE Campus Way <br />Hillsboro, OR 97124-5611 <br />1.855.4DENTAL (1-855-433-6825) <br />d. If the Enrollee is unsatisfied after discussion with the Participating Provider, <br />Participating Provider's staff, or Member Services Department, grievance and appeal <br />procedures are available. <br />7.3.2 Grievances. <br />a. A grievance is a written complaint expressing dissatisfaction with a service provided <br />by the Company or other matters related to this Contract. The Enrollee should outline <br />his/her concerns and specific request in writing. The Enrollee may submit comments, <br />documents, and other relevant information. Grievances must be submitted to the <br />Member Services Department no later than 180 days after the event occurred. <br />b. The Company will review the grievance and all information submitted. The Company <br />will provide a written reply no later than 30 days after receipt. If additional time is <br />needed, the Company will provide written notification of the reason for the delay and <br />the extension of time allowed, per applicable state and federal laws. If the grievance <br />involves: <br />1. A preauthorization, the Company will provide a written reply no later than 15 days <br />after the receipt of a written grievance. <br />2. Services deemed Experimental or Investigational, the Company will provide a <br />written reply no later than 20 working days after the receipt of a written grievance. <br />3. Services not yet provided for an alleged Dental Emergency, the Company will <br />provide a reply no later than 72 hours of the receipt of a written grievance. <br />c. If the grievance is denied, the written reply will include information about the basis for <br />the decision, how to appeal and other disclosures as required under state and federal <br />laws <br />001 L-WA811(5/20) 20 <br />