Appeals Process for Rhode Island Residents or Services

You may also have the right to appeal as described in this section when a claim is denied as being not necessary and appropriate. If so, these rights are in addition to the other rights to appeal that you have as described in other parts of this site. The following provisions apply only to:

• A member who lives in Rhode Island and is planning to obtain services that Blue Cross and Blue Shield has determined are not necessary and appropriate.
• A member who lives outside Rhode Island and is planning to obtain services in Rhode Island that Blue Cross and Blue Shield has determined are not necessary and appropriate.

Blue Cross and Blue Shield decides which covered services are necessary and appropriate for your dental condition based on a review of your dental records and generally accepted dental practice. Some of the covered services described in this contract may not be necessary and appropriate for you. If Blue Cross and Blue Shield has determined that services are not necessary and appropriate for you, you have the right to the following appeals process:

Reconsideration

Reconsideration is the first step in this appeals process. If you receive a letter denying payment for your dental services, you may request that Blue Cross and Blue Shield reconsider its decision by writing to: Member Grievance Program, Blue Cross and Blue Shield of Massachusetts, Inc., One Enterprise Drive, Quincy, MA 02171-2126. You must submit your reconsideration request within 180 days of the adverse decision. Along with your letter, you should include any information that supports your request. Blue Cross and Blue Shield will review your request and let you know the outcome of your reconsideration request within 15 calendar days after receipt of all necessary information.

Appeal

An appeal is the second step in this process. If Blue Cross and Blue Shield continues to deny benefits for all or part of the original service, you may request an appeal within 60 days of receiving the reconsideration denial letter. Your appeal request should include any information that supports your appeal. You may also inspect and add information to your Blue Cross and Blue Shield case file to prepare your appeal. In accordance with Rhode Island state law, if you wish to review the information in your Blue Cross and Blue Shield case file, you must make your request in writing and include the name of a dentist who may review your file on your behalf. Your dentist may review, interpret, and disclose any or all of that information to you. Once received by Blue Cross and Blue Shield, your appeal will be reviewed by a dentist in the same specialty as your attending dentist. Blue Cross and Blue Shield will notify you of the outcome of your appeal within 15 calendar days of receiving all necessary information.

External Appeal

If your appeal is denied, you have the right to present your case to an appeals agency that is designated by Rhode Island and not affiliated with Blue Cross and Blue Shield. If you request this voluntary external appeal, Rhode Island requires you be responsible for half of the cost of the appeal. Your group will be responsible for the remaining half. The notice you receive from Blue Cross and Blue Shield about your appeal will advise you of: the name of the appeals agency that is designated by Rhode Island; and your share of the cost for an external appeal. To file an external appeal, you must make your request in writing to: Member Grievance Program, Blue Cross and Blue Shield of Massachusetts, Inc., One Enterprise Drive, Quincy, MA 02171-2126. Along with your request, you must state your reason(s) for your disagreement with Blue Cross and Blue Shield’s decision and enclose a check made payable to the designated appeals agency for your share of the cost for the external appeal.

Within five working days after the receipt of your written request and payment for the appeal, Blue Cross and Blue Shield will forward your request to the external appeals agency along with Blue Cross and Blue Shield’s portion of the fee and your entire Blue Cross and Blue Shield case file. The external appeals agency will notify you in writing of the decision within ten working days of receiving all necessary information.

Expedited Appeal

If your situation is an emergency, you have the right to an expedited appeal at all three levels of appeal as stated above. An emergency requires emergency dental treatment to relieve acute pain or to control a dental condition that requires immediate care to prevent permanent harm to the member. You may request an expedited reconsideration or appeal by contacting Blue Cross and Blue Shield at the telephone number shown in your letter. Blue Cross and Blue Shield will notify you of the result of your expedited appeal within 72 hours of its receipt. If your appeal is denied, you have the right to request an expedited external appeal. The notice you receive from Blue Cross and Blue Shield about your appeal will advise you of: the name of the appeals agency that is designated by Rhode Island; and the amount that Rhode Island requires you pay for your share of the cost for an expedited external appeal. To request an expedited external appeal, you must send your request in writing to: Member Grievance Program, Blue Cross and Blue Shield of Massachusetts, Inc., One Enterprise Drive, Quincy, MA 02171-2126. Your request should state your reason(s) for your disagreement with the decision and include signed documentation from your dentist that describes the emergency nature of your treatment. In addition, you must also enclose a check made payable to the designated appeals agency for your share of the cost for the expedited external appeal.

Within two working days after the receipt of your written request and payment for the appeal, Blue Cross and Blue Shield will forward your request to the external appeals agency along with Blue Cross and Blue Shield’s portion of the fee and your entire Blue Cross and Blue Shield case file. The external appeals agency will notify you in writing of the decision within two working days or 72 hours, whichever is sooner, of receiving your request for a review.

External Appeal Final Decision

If the external appeals agency upholds the original decision of Blue Cross and Blue Shield, this completes the appeals process for your case. But, if the external appeals agency reverses Blue Cross and Blue Shield’s decision, the claim in dispute will be reprocessed by Blue Cross and Blue Shield upon receipt of the notice of the final appeal decision. In addition, Blue Cross and Blue Shield will repay you for your share of the cost for the external appeal within 60 days of the receipt of the notice of the final appeal decision.