Review and Appeals Procedures

(Effective as of January 1, 2011)
The below content is from the Participating Handbook.

1. Applicability and Effective Date
These Rules apply only to dentists who participate with Delta Dental of New Jersey, Inc. (“Participating Dentists”). They apply only to “claims” determinations. As used in these Rules, “claims” mean requests by covered persons or Participating Dentists for payment relating to dental services or supplies covered under a dental plan issued by Delta Dental of New Jersey, Inc. (“Delta Dental”). “Claims” do not include actions taken by Delta Dental to request or obtain recoupment of payments Delta Dental had previously made to Participating Dentists and/or covered persons; such actions are not subject to these Rules. These Rules are effective January 1, 2011 or ten days following the Participating Dentist’s receipt of these Rules, whichever is later. Any revision of these Rules is subject to the prior approval of the New Jersey Department of Banking and Insurance.

2. Informal Requests for Re-Review of Claims Determinations (at the option of the Participating Dentist)
A. Participating Dentists have the option to request that Delta Dental re- review its initial claim determination prior to filing an internal appeal pursuant to Rule 3. Any request for re- review shall be in writing, shall either be mailed to Delta Dental of New Jersey at P.O. Box 15132, Little Rock, AR 72231, Attention “Director of Customer Service — Request for Review” or faxed to Delta Dental at (973) 285-4095 with a cover form addressed to “Request for Re-Review” within thirty (30) days following the Participating Dentist’s receipt of the claim determination for which informal review is requested. The Participating Dentist may supplement his or her initial claim submission with information or documentation pertinent to the claim which had not previously been provided to Delta Dental. Delta Dental will inform the Participating Dentist within fifteen (15) business days of Delta Dental’s decision on informal re-review.
B. Participating Dentists who request re-review of a claim pursuant to Rule 2.A. have the right to file an internal appeal pursuant to Rule 3 if they are not satisfied with Delta Dental’s decision on re-review.
C. Participating Dentists incur no fee for the informal request for review. Participating Dentists need not complete or submit any particular form to Delta Dental for re-review.

3. Internal Appeals
A. Participating Dentists have the right to file an internal appeal from claim determinations by Delta Dental in accordance with this rule whether or not the Participating Dentist has elected to informally request re-review of the claim as per Rule No. 2.
B. Each internal appeal must be mailed to Delta Dental of New Jersey, PO Box 15132, Little Rock, AR 72231, to the attention of “Internal Appeals Program Coordinator” within thirty (30) days of the Participating Dentist’s receipt of the (i) claim determination or (ii) Delta Dental’s decision on re-review as per Rule No. 2, whichever is later. The Participating Dentist must complete and submit the internal appeal form attached to these Rules as Form 1A. A separate form must be submitted for each claim for which internal review is requested.
C. Delta Dental will reject internal appeals that are not timely mailed as required by Rule 3.B. and notify the Participating Dentist in writing of the reason for the rejection of the appeal.
D. Delta Dental will resolve all internal appeals that were timely and properly submitted in accordance with Rule 3.B. and will do so within ten (10) business days of Delta Dental’s receipt thereof. However, if the internal appeal is timely filed but the appeal form does not contain all of the required information and/or documentation, Delta Dental will within ten (10) days of its receipt thereof, notify the Participating Dentist in writing (by fax if Delta Dental knows the Participating Dentist’s facsimile number) of the information and/or documentation that was missing and provide the Participating Dentist thirty (30) days within which to cure the deficiency. If the Participating Dentist cures the deficiency, Delta Dental will resolve the internal appeal within ten (10) business days of Delta Dental’s receipt of the missing information and/or documentation. If a Participating Dentist fails to cure the deficiency within the time period set forth in rule 3.B. the internal appeal will be deemed to have been withdrawn by the Participating Dentist.
E. Internal appeals shall be handled at no cost to the Participating Dentist.
F. Internal appeals shall be reviewed and resolved by one or more employees of or consultants retained by Delta Dental who are not responsible for making claims determinations on a day-to-day basis.
G. Delta Dental will mail its determination of each internal appeal to the address provided by the Participating Dentist in its internal appeal request. Each such determination shall be in writing and contain the following information:
(i) the name(s), title(s) and qualifying credentials of the person(s) participating in the internal review;
(ii) a statement of the Participating Dentist’s grievance;
(iii) the reviewer’s decision, including a detailed explanation of the contractual and/or dental basis for the decision;
(iv) a description of the information and/or documentation which supports the decision;
(v) if adverse, a description of the method to obtain an external review of the decision.

4. External Appeals
A. Participating Dentists have the right to seek external review of adverse decisions issued pursuant to Rule 3 hereof.
B. The Participating Dentist must complete and submit the external appeal form attached to these Rules as Form 1B for each internal appeal decision for which external review is requested, together with 50 percent of the applicable AAA fee for non-binding arbitration for businesses. The fee amounts are available here. The arbitrator’s fee is addressed in section 4.I below.
C. The Participating Dentist shall mail the external appeal documents to Delta Dental of New Jersey, PO Box 15132, Little Rock, AR 72231 to the attention of External Appeals Program Coordinator, within thirty (30) days of the Participating Dentist’s receipt of the decision issued pursuant to Rule 3.
D. Delta Dental will reject any external appeal that was not timely submitted pursuant to Rule 4.C. and notify the Participating Dentist of the rejection within thirty (30) business days of Delta Dental’s receipt of the external review.
Delta Dental will notify the Participating Dentist of any external appeal that did not contain all of the information and/or documentation required by Rule 4.B. If the Participating Dentist fails to cure the deficiency within thirty (30) days, the external appeal will be deemed to have been withdrawn by the Participating Dentist and the filing fees (if any) will be returned to the Participating Dentist.
E. All external appeals that have been submitted and/or revised in conformity with Rule 4 will be forwarded by Delta Dental within thirty (30) days to the American Arbitration Association for non-binding dispute resolution pursuant to the Expedited Procedures provisions of the AAA Commercial Arbitration Rules for a non-binding review by a single arbitrator at a hearing locale (if any) at the AAA location closest to Morristown, New Jersey.
F. Delta Dental’s submission pursuant to Rule 4.E. will contain the Participating Dentist’s Form 1B together with a copy of Delta Dental’s Internal and External Appeals Rules and Regulations, a copy of Delta Dental’s internal review decision, and Delta Dental’s response to the Participating Dentist’s Form 1B.
G. The AAA arbitrator shall resolve the dispute without the submission of any additional information and/or documentation and without a conference unless the arbitrator determines in his or her sole discretion that a conference is necessary, in which event the arbitrator shall determine whether to hold the conference in person or by telephone.
H. The Participating Dentist and Delta Dental shall have three (3) business days to strike the names of arbitrators provided by AAA, to number the remaining arbitrators in order of preference and to return the list to the AAA.
I. In addition to the AAA fees which Delta Dental and the Participating Dentist shall each pay pursuant to Rule 4.B., Delta Dental and the Participating Dentist will bear 50% of the costs of the arbitrator.
J. If both the Participating Dentist and Delta Dental agree in writing within ten (10) days after the perfection of the appeal pursuant to Rule 3, they may elect a different independent external reviewer, a different appeal procedure, a different allocation of the appeal costs and/or to make the arbitration binding (rather than non- binding).

Reviews and Appeals
The reverse side of our current Explanation of Benefits describes available alternatives for reviews and appeals of claim determinations. A copy is included for your information on page 2-11. From time to time we update this document. Therefore, please be sure to review the back of the EOB when requesting a review or appeal. You may also check our website www.deltadentalnj.com for periodic revisions and updates.

Adverse Dental Decision Reviews (New Jersey Only)
New Jersey law gives New Jersey treating dentists the right to communicate directly with a reviewing dentist when the carrier’s decision is based on a dental judgment or diagnosis, the treating dentist disagrees with that dental judgment or diagnosis and the treating dentist explains the disagreement in writing and requests to confer with the carrier’s review dentist. If you wish to request this review relating to a Delta Dental claim decision, you must submit a written and signed explanation of the basis for your disagreement within the time period for challenging the claim determination to Delta Dental of New Jersey, Attn: Adverse Determination Review, P.O. Box 15132, Little Rock, AR 72231. We urge you to include any documentation you want us to consider.

Form 1A - Delta Dental of New Jersey Request for Internal Review

Form 1B - Delta Dental of New Jersey Request for External Review

Please note: Effective April 11, 2008, dentists licensed in New Jersey can request to speak with a dentist at Delta Dental.

Notice Regarding Dental Decisions by Dental Dental

New Jersey Licensed Dentists
(Effective as of April 11, 2008)

 A "dental decision" is a decision that is based upon a dental diagnosis or dental judgment. If you have received an Explanation of Benefits or Pre-Treatment Estimate that reports a denial, reduction or failure to provide payment, in whole or in part, for a service based upon a "dental decision" AND (a) you are a New Jersey licensed dentist AND (b) you disagree with such determination, then you have the right to speak with a dentist at Delta Dental concerning the dental basis for the dental decision. As a precondition, you must submit a written and signed explanation of the basis for your disagreement within the time period for challenging the claim determination to Delta Dental of New Jersey, Attn: Adverse Determination Review, P.O. Box 15132, Little Rock, AR 72231. Please include any documentation you want us to consider.

Updated 01/25/16.