Formal Appeals Process

After a claim is processed, an Explanation of Benefits (EOB) will be sent to the subscriber. If any payment for services was denied, the EOB will give the reason why. If the subscriber disagrees with the denial he or she must submit a request in writing asking that the claim be reviewed. Such request should include the reason why the subscriber believes the claim was wrongly denied. The request must be received by Delta Dental of Tennessee within 180 days of the subscriber’s receipt of the EOB. Delta Dental of Tennessee will make a review and may ask for more documents if needed. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental of Tennessee receives the request for review.

If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of Delta Dental of Tennessee. This second level review request must be in writing and received by Delta Dental of Tennessee within a reasonable time after the subscriber receives the first level review decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental of Tennessee receives the request for second level review. If the subscriber does not agree with the second level review decision, he or she may file civil action in court.