Triage Tactics
When a member has completed all levels of internal and external review and no further appeal options remain, this term describes their status."
What is exhausted appeal rights?
Delta Dental’s (general) guidelines require that standard grievances be resolved within this number of calendar days. Excluding PG's and Special Handle groups.
What is 30 days?
When a member requests reconsideration of a denied service because they believe it should be included in their plan benefits, this category applies
What is a Coverage Dispute?
According to Delta Dental policy, a provider or member must submit an appeal within this number of calendar days from the initial denial notice
What is 180 calendar days?"
Any complaint or inquiry received by this level of staff qualifies as an executive complaint and must follow special handling protocols.
What is director level or above?
This process involves assigning a grievance or appeal to the correct type, such as clinical or administrative, to ensure proper handling.
What is categorization?
When a member complains about poor diagnostic standards or inadequate treatment, this category applies.
What is Quality of Care?
An appeal challenging a denial based on whether a treatment is clinically appropriate falls under this category."
What is a Medical Necessity Appeal?
Every adverse determination letter must include this information to ensure members and providers know their options.
What is a written notice of appeal rights?
Executive complaints must be resolved and communicated to the member within this number of calendar days from receipt.
What is 10 calendar days?
Before accepting a grievance filed by someone other than the member, you must confirm this legal document granting permission.
What is authorization to act on behalf of an adult (AOR)?
If a grievance involves rude behavior or poor customer service from the plan or provider, it falls under this category.
What is Attitude and Service?
Before issuing a manual payment outside the claims system, staff must complete this document detailing member and claim information.
What is the Manual Check Request Form (FFS) or OTP form (DHMO)?
All clinical appeals must be reviewed by this type of professional, ensuring impartiality and expertise.
What is a dental consultant?
When a licensed attorney submits an appeal on behalf of a member, this department must review the resolution letter and case details before resolving the complaint.
What is Legal?
When a member asks for copies of their medical or claim documents without disputing a decision, this type of request is classified as this.
What is a misdirect?
When a grievance investigation confirms the member’s complaint is valid and corrective action is required, this outcome is recorded.
What is substantiated?
If a member claims they did not cash a check, staff must request this packet from Finance to begin their investigation.
What is an affidavit packet?"
When an Independent Review Organization completes an external review, this is the effect of its decision on Delta Dental.
What is binding on Delta Dental?
When a member uses abusive language or behaves aggressively during a call, staff must follow this specific policy.
Abusive Customer Policy
When a member’s health could be seriously jeopardized by waiting for a standard review, this type of appeal is requested for faster resolution.
What is an expedited appeal?
If a member cannot find a contracted provider or experiences delays in scheduling, this category applies.
What is Access to Care?
When a member disputes a delay in coverage and requests that the plan remove or shorten the waiting period based on eligibility or prior coverage, this type of appeal applies.
What is a waiting period waiver appeal?
Under Delta Dental’s external appeal process, this is the fee charged to members or providers for an IRO review.
What is no fee?
When a member requests a copy of their case file, this team is responsible for reviewing all contents—before sending the packet.
What is Privacy Investigator or Risk, Ethics & Compliance?