Page 35 - Dental Benefit Plan Summary
P. 35
TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN
The tables below describe the time frames which you and the Claims Administrator are
required to follow.
Urgent Care Claims
*
Type of Claim or Appeal Timing
If your claim is incomplete, UnitedHealthcare Dental must 24 hours
notify you within:
You must then provide completed claim information to 48 hours after
UnitedHealthcare Dental within: receiving notice
If your initial claim is denied, UnitedHealthcare Dental must notify you of the denial:
■ if the initial claim is complete, within: 72 hours
■ after receiving the completed claim (if the initial claim is
incomplete), within: 48 hours
180 days after
You must appeal the claim denial no later than:
receiving the denial
UnitedHealthcare Dental must notify you of the appeal 72 hours after
decision within: receiving the appeal
* You do not need to submit Urgent Care appeals in writing. You should call UnitedHealthcare
Dental as soon as possible to appeal an Urgent Care claim.
Pre-Service Claims
Type of Claim or Appeal Timing
If your claim is filed improperly, UnitedHealthcare Dental
must notify you within: 5 days
If your claim is incomplete, UnitedHealthcare Dental must 15 days
notify you within:
You must then provide completed claim information to 45 days after receiving
UnitedHealthcare Dental within: an extension notice
*
If your initial claim is denied, you must be notified of the denial:
■ if the initial claim is complete, within: 15 days
■ after receiving the completed claim (if the initial claim is
incomplete), within: 15 days
180 days after
You must appeal the claim denial no later than:
receiving the denial
30 SECTION 6 - CLAIMS PROCEDURES
