Appeals and State Fair Hearings

If you are not satisfied with our decision about your care, you have the right to file an appeal:

• If you are not satisfied with an action we took or what we decided about your prior authorization request (see pages 19-20) about prior authorizations and actions), you can file an appeal. An appeal is a request for us to review the decision. You have 60 days after you get a written notice of adverse benefit determination from us to file an appeal.
  
  
• You can do this yourself or, with your written consent, your authorized representative or your provider can call Member Services at 1-833-479-0687 or visit our website at www.MySoonerCare.org if you need help filing an appeal.
  
  
• The appeal can be made by phone or in writing. You don’t have to use any specific or legal terms; just clearly state that you are dissatisfied with the decision we made. We can help you complete the appeal form. If needed, additional aids and services will be provided to you free upon request.
  
  
• If your appeal review needs to be reviewed more quickly than the standard timeframe because you have an immediate need for dental services, you may file an expedited appeal instead of a standard appeal.
  • Standard appeals: If we have all the information we need, we will tell you our decision in writing within 30 days from your appeal.
  • Expedited (faster) appeals: If we have all the information we need, we will call you and send you a written notice of our decision within 72 hours from your appeal. We’ll let you know we received your expedited appeal within 24 hours.
     
• You may file a grievance if your request for an expedited appeal is denied.
  
  
• We will not treat you any differently or act badly toward you because you file an appeal.
  • To file an appeal in writing, write to: PO Box 2906 Milwaukee, WI 53201
  • To file an appeal by phone, call Member Services at 1-833-479-0687.
     
• Before and during the appeal, you or your representative can see your case file, including dental records and any other documents and records, being used to decide on your case.
  
  
• You can ask questions and give any information (including new documents from your providers) that you think will help us approve your request. You may do that in person, in writing, or by phone.
  
  
• If you need help with the appeals process, have questions or want to check the status of your appeal, you can call Member Services at 1-833-479-0687.

If we need more information to make either a standard or an expedited decision about your appeal, we will:

• Write you and tell you what information is needed. For expedited appeals, we will call you right away and send a written notice later.
  
  
• Explain why the delay is in your best interest.
  
  
• Decide no later than 14 days from the day we asked for more information.

If you need more time to get your documents and information, just ask. You, your provider, or someone you trust may ask us to delay your case until you are ready. We want to make the decision that best supports your health. You can ask for more time by calling Member Services at 1-833-479-0687 or writing to PO Box 2906 Milwaukee, WI 53201.

Your Care While You Wait for a Decision

• When the dental plan’s decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we are deciding on your appeal. You can also ask an authorized representative to make that request for you. Providers are not allowed to ask for your services to continue for you.
  
  
• While you are waiting for us to decide on your appeal, if you want to continue services you were already receiving, be sure to ask us to continue those services within 10 days after we mail the adverse benefit determination or before the effective date of our adverse benefit determination, whichever is later. Under most circumstances, that will be enough to continue the services you were receiving. Some services you were already receiving must be continued even if you don’t ask us to continue them.
  
  
• If we continue the services you were already receiving, we will pay for those services if your appeal is decided in your favor. Your appeal might not change the decision the dental plan made about your services.
  
  
• If you are unhappy with the result of your appeal, you can ask for a state fair hearing (see next section).

After you receive a notice of adverse resolution to your appeal, you can ask for a state fair hearing if you still don’t agree with the decision we made that reduced, stopped or restricted your services. A state fair hearing is your opportunity to give more information and ask questions about the decision in front of an administrative law judge. The judge in your state fair hearing is not a part of your dental plan in any way.

If you want to continue benefits while you wait for the administrative law judge’s decision about your state fair hearing, you must request a state fair hearing and continuation of benefits within 10 days after we send you the notice of adverse resolution on your appeal.

If you need help with understanding the state fair hearing process, you can call Member Services at 1-833-479-0687. You don’t have to use any special legal or formal language to ask for a state fair hearing.

Your Care While You Wait for a Decision

• If you asked for and received continued services during your appeal, we must continue providing those services until you do one of the following:
  • You withdraw your appeal or your request for a state fair hearing;
  • You don’t ask for a state fair hearing and continuation of benefits within 10 days after we send you notice of an adverse resolution to your appeal; or
  • A state fair hearing officer or administrative law judge issues a hearing decision that disagrees with you.
     
• You can also ask a trusted representative to make that request for you.
  
  
• If you ask your dental plan to continue services you already receive during your state fair hearing case, the dental plan will pay for those services if your case is decided in your favor. Your state fair hearing might not change the decision the dental plan made about your services. When your state fair hearing case doesn’t change the decision, you may be required to pay for the services you received while waiting for a decision.
   

Requesting a State Fair Hearing

• You don’t have to use any special legal or formal language to request a state fair hearing.
  
  
• You must first file an appeal with DentaQuest and receive our decision before asking for a state fair hearing. If we don’t decide your appeal within 30 days of your appeal request, you can also ask for a state fair hearing.
  
  
• You don’t need an attorney for your state fair hearing, but you may use one.
  • You may represent yourself or allow someone else to represent you.
  • If you let someone else represent you, they will have to show proof in writing that you asked for their help.
     
• Without this written proof, your appeal will be rejected.
  
  
• You can ask for a state fair hearing at any time within 120 days from the day we send you notice of adverse resolution.
  
  
• You can use one of the following ways to request a fair hearing:
  • By phone – 1-833-479-0687 TDD/TTY 711
  • By fax – (262) 834-3589 
  • By internet – www.MySoonerCare.org
  • By mail – PO Box 2906 Milwaukee, WI 53201