Grievances & Appeals

How to File a Grievance or ask for an Appeal? 

What is a Grievance?

A grievance is a complaint about:

  • Delta Dental Smiles
  • Delta Dental of Arkansas
  • A dentist
  • Services you received

How Do I File a Grievance?

You can file a grievance by doing one of the following:

  • Call toll-free at 1-866-864-2499. 
  • Send a fax to 1-833-866-4650
  • Write us at:

Delta Dental Smiles
Attn:  Appeals and Grievances
P.O. Box 6247
Sherwood, AR 72124

Processes and Timeframes

We will let you know we received your grievance.  We will return a summary of the process and timetable for resolving the grievance.

  • We will respond to a grievance within 30 calendar days of receipt.
  • We may extend the timeframe by up to 14 days if:
    • You or someone speaking for you requests the extension.
    • We think there is a need for more information or a delay may be in your best interest.   
  • If we extend the timeframe we will:
    • Give you notice of the delay.
    • Provide notice that you may file a grievance about the decision to delay.
    • Resolve the grievance as fast as possible and no later than the date the extension expires.
  • Delta Dental will respond to a grievance in writing within the timeframes described above.
  • A State Fair Hearing is not available for a grievance.

What is an Appeal?

An Appeal is a request for a review of an action by Delta Dental.  An Appeal can be for any of the following:

  • Denial of services or where we only approved part of a service.
  • Limiting or stopping services that had been approved.
  • Denial of all/part of a payment for a service.
  • Not providing services fast enough.
  • Not acting within time limits for appeals and grievances.

Processes and Timeframes

Filing

You can appeal by calling or writing to us within 60 calendar days after you receive the denial, reduction or failure to pay notice.  You must follow up a call with a written appeal.

We will let you know we got your appeal and give you a summary of the process and timetable for resolving the appeal.  This will include information on the following: 

  • The time for you to present evidence or testimony and to make legal and factual arguments.
  • Your right to request records from the file relating to your appeal.  This may include dental records and other evidence used by Delta Dental or its representatives.
  • The timetable we will follow until we send the final decision. 

Timing

We will resolve an appeal within these times:

  • Standard non-clinical appeals: Within 30 calendar days of receiving your appeal.
  • Non-emergency appeals that involve active clinical issues: Within 5 business days of receiving your appeal.
  • Appeals related to ongoing issues involving Emergency Care: Within 24 hours of receiving your appeal or by the close of the next business day.

Extensions

We may extend the timeframes by up to 14 calendar days if:

  • You request an extension; or
  • We think there is a need for more information, a delay may be in your best interest.

If we extend the timeframe we will:

  • Give you quick notice of the delay.
  • Provide notice that you may file a grievance about the decision to delay.
  • Resolve the appeal as fast as required by your health condition, and no later than the date the extension expires.

If Delta Dental does not follow the times above, you can move to the State Fair Hearing process.

Opportunity to Request Hearing on Appeal

If you ask to provide written or spoken testimony, we will give you an opportunity before a decision on the Appeal is made.  You may be represented by an Attorney.

Resolution of Appeal

A decision on an appeal will be in writing.  We will use our best efforts to call to inform you of the results of an expedited Appeal. 

State Fair Hearing

If you are not happy with our decision on your appeal, the second step in the appeal process is to ask for a State Fair Hearing.  You must ask for this within 120 calendar days of receiving the appeal decision. 

To request a hearing write to:

Arkansas Department of Human Services
Attn: Arkansas Medicaid Appeals Liaison
700 Main Street
Little Rock, AR 72201

You can speak for yourself or have someone else speak for you.  This could be:

  • A friend
  • A relative
  • A spokesperson
  • A lawyer

Your dentist may ask for a State Fair Hearing for you.  You need to give your dentist approval in writing first.  We will give you a form to sign if you tell us.  This form will say that you know your health information may be shared publically during the State Fair Hearing process. 

Continuing Your Benefits

You can ask for your benefits to continue during the Appeal and Fair Hearing processes. All of the following must apply:

  • Your Appeal has to do with a change in our approval of care already in place.
  • Your initial appeal was filed within the time limits stated above. 
  • The services were ordered by an approved dentist.
  • The approved time of service has not expired. 
  • You made a request on or before the later of the following dates:
    • 10 calendar days from the date of our notice to you limiting your child’s benefits; or
    • The intended effective date of the action stated in the notice.

We will pay for the services you asked to be continued if the State Fair Hearing decision is in your favor.  If it is not in your favor, you may have to pay for all or part of the services used.