What should I do if I would like to file a grievance?
A grievance is a complaint you let Delta Dental know about. It may be about dissatisfaction with a dental provider, the MIHealth Link program or Delta Dental. If you would like to file a grievance (also called a complaint), you can call customer service at 800-838-8957, or send your grievance in writing to:
Delta Dental
Attn: Grievances
PO Box 9230
Farmington Hills, MI 48333-9230
Fax:517-334-4939
Please be sure to include a full explanation of your grievance in your letter. Delta Dental will investigate your grievance and respond to you within 30 days of receiving your complaint.
What should I do if I would like to appeal a payment or coverage determination?
You have the right to ask Delta Dental to review our decision by asking for an internal appeal. You can ask for an internal appeal within 60 calendar days of the date on the notice of denial of payment or coverage. We can give you more time if you have a good reason for missing the deadline.
If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. If you want the service to continue while your case is under review, you must ask for an appeal within 10 calendar days of the date of this notice or before the service is stopped or reduced, whichever is later. You could be responsible for the cost of services if our decision is upheld.
You, your representative, or your provider must ask us for an internal appeal. Your request must include:
• Your Name
• Address
• Member Number
• Reasons for appealing
• Whether you want a Standard or Fast Appeal (for a Fast Appeal, explain why you need one)
• Any evidence you want us to review, such as medical records, providers' letters (such as a provider's supporting statement if you request a fast appeal), or other information that explains why you need the medical services/items. Call your provider if you need this information.
This information may be provided in person and in writing. There is limited time available to provide additional information, especially in the case of a fast appeal.
We recommend keeping a copy of everything you send us for your records. You can ask to look at the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.
Step 2: Mail, fax, or deliver your appeal or call us.
For a Standard Appeal:
Mailing Address:
Delta Dental
Attn: Appeals
P.O. Box 9230
Farmington Hills, MI 48333-9230
Phone: 1-800-838-8957
TTY Users Call: 711
Fax: 517-381-5527
For a Fast Appeal (applicable only to coverage determinations):
Phone: 1-800-838-8957
TTY Users Call: 711
FAX: 517-381-5527
What happens next?
If you ask for an internal appeal, we will give you a written decision within 30 calendar days. If you ask for an internal appeal and we continue to deny your request for coverage or payment of a medical service/item, we’ll send you a written decision. The letter will tell you if the service or item is usually covered by Medicare and/or Michigan Medicaid.
• If the service is covered by Medicare, we will automatically send your case to an independent reviewer. If the independent reviewer denies your request, you will receive a written decision that will explain if you have additional appeal rights.
• If the service is covered by Michigan Medicaid, you can ask for a Fair Hearing. You can also ask for an External Review under the Patient Right to Independent Review Act (PRIRA). Your written decision will give you instructions on how to request a Fair Hearing and External Review.
• If the service could be covered by both Medicare and Michigan Medicaid, we will automatically send your case to an independent reviewer. You can also ask for a Fair Hearing or an External Review.
• If you do not receive a notice or decision about your appeal from the plan within the timeframes listed above, you may seek a Fair Hearing. For more information or to ask for a Fair Hearing, contact the Michigan Office of Administrative Hearings and Rules (MOAHR) at 1 800 648 3397.
How do I ask for a fast appeal?
You can ask for a fast appeal of your coverage determination, if you or your provider believe your health could be seriously harmed by waiting up to 30 calendar days, for a coverage decision. You cannot ask for an expedited appeal for a service/item you have already received. We’ll automatically give you a fast appeal if a provider asks for one for you or if your provider supports your request. If you ask for a fast appeal without support from a provider, we’ll decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you a decision within 30 calendar days. We’ll give you a decision on a fast appeal within 72 hours after we get your appeal.
How does someone else act on my behalf?
You can name a relative, friend, attorney, provider, or someone else to act as your representative. If you want someone else to act for you, call us at: 1-800-838-8957 to learn how to name your representative. TTY users call 711. Both you and the person you want to act for you must sign and date a statement confirming this is what you want. You must submit via mail or fax the form titled “Medicare Advantage and TriState Advantage Appointment of Representative Form” in the link below to be considered a valid appointment of representation. Keep a copy for your records.
https://deltadentalmi.com/Member/Using-Your-Benefits/Forms-Resources/Appointment-of-Representative-Form
Back To MI Health Link