Program Basics
This is what CSM stands for
What is Customer Service Module?
This is the timeframe for resolving a member complaint
What is within 30 calendar days from the date the complaint was received?
Members have this many calendar days to file an appeal after receiving notice
What is 60 calendar days?
This situation qualifies an exception to recovering cost
What is when the appeal is overturned in the member's favor?
These are three examples of additional resources available when UHC does not cover a benefit
What are Maximus, 211, Community Resources, or Social Services?
Two lines of business covered by TX Children's Dental product
What are Medicaid and CHIP?
(TX CHIP $0, $5, $20, $25)
A member may file a complaint for issues such as benefits, appointments, or this billing issue
What is a complaint about benefits, services, appointments, or billing?
This is the timeframe for sending an appeal acknowledgment letter
What is within 5 business days?
This is the timeframe for resolving an expedited appeal
What is within 72 hours?
This person may file a complaint or appeal on behalf of a member
Who is an authorized representative?
These are the primary ways leadership communicates major program changes
What are meetings, email notifications, town halls, and Best Practice meetings?
A complaint can be submitted using these two methods
What are verbal and written submissions?
This is the standard timeframe to resolve an appeal
What is within 30 calendar days?
These individuals may request an expedited appeal
Who are the member, provider, doctor, or authorized representative?
This type of billing is prohibited for covered Medicaid services
What is balance billing?
This is how non-major updates are typically distributed
What is email communication?
A Dental Member Experience takes these steps to resolve a complaint
What is gather information from member, apologize to the member for their experience, resolve any additional questions, and send a follow-up to the Complaints and Grievance Department. Then give the member the turnaround times on complaints.?
Under certain circumstances, appeals may be extended by this many additional calendar days
Double Jeopardy
Extension circumstances
What is 14 additional calendar days?
If requested by member/RP or UnitedHealthcare Dental determines more information is needed or an extension is in your child’s best interest, we will notify you in writing.
If UHC denies expedited processing, the member must be notified in this manner
What is written notification within 72 hours?
Members have at least 13 rights (name at least 3)
Member rights
1. You have the right to get accurate, easy-to-understand information to help you make good choices about you or your child’s dentists and other providers.
2. You have the right to know how your child’s dentists are paid. You have a right to know about what those payments are, and how they work.
3. You have the right to know how UnitedHealthcare Dental decides about whether a service is covered or medically necessary. You have the right to know about the people in UnitedHealthcare Dental’s office who decide those things.
4. You have the right to know the names of the dentists and other providers enrolled with UnitedHealthcare Dental and their addresses.
5. You have the right to pick from a list of dentists that is large enough so that your child can get the right kind of care when your child needs it.
6. You have the right to take part in all the choices about your child’s dental care.
7. You have the right to speak for your child in all treatment choices.
8. You have the right to get a second opinion from another dentist enrolled with UnitedHealthcare Dental about what kind of treatment your child needs.
9. You have the right to be treated fairly by UnitedHealthcare Dental, dentists, and other providers.
10. You have the right to talk to your child’s dentists and other providers in private, and to have your child’s dental records kept private. You have the right to look over and copy your child’s dental records and to ask for changes to those records.
11. You have a right to know that dentists, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your child’s dental health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
12. You have a right to know that you are not responsible for paying for covered services for your child. Dentists, hospitals, and others cannot require you to pay any other amounts for covered services.
13. You have the right not to be secluded or restrained as a punishment or to make things easier for your provider.
These are two resources used to verify covered member benefits
What are the Member Handbook and Member Portal?
If dissatisfied with the complaint outcome, members can contact this state agency
What is the Texas Department of Insurance or Ombudsman?
Members must request an appeal within this timeframe to potentially continue services during the appeal process
What is within 10 business days from the denial letter or before the effective date of the denial letter?
Your services may continue while your appeal is being looked at, if all the following apply:
• You ask for an appeal:
– Within 10 business days from the date we mailed the denial letter, or
– Before the effective date of the denial letter.
• The appeal request is related to reduced or suspended services or to services that were previously authorized by you
• The services were ordered by an authorized provider
• The authorization period for the services has not ended
• You asked that the service continue
If the Medicaid Member's expedited appeal decision is unfavorable, the member still has this next level of review available
What is a State Fair Hearing with optional External Medical Review?
A Member Advocate can assist members with at least three of these services
What are assigning a main dentist, transportation coordination, interpreter assistance, provider searches, and community resources?