bcl_720451015.htm

WRITTEN MEMBER GRIEVANCE AND APPEAL FORM – FLORIDA

You can use this form to file a grievance or appeal with LIBERTY Dental Plan (LIBERTY).You can also use this form to give LIBERTY more information to help review your case. If you filed an appeal over the telephone, you can also complete this form and mail back to LIBERTY. This is optional. We will review your case without a written appeal.

MEMBER INFORMATION (PLEASE PRINT)

Member last name	Member first name		Today’s date

Member street address	City		State	ZIP code

Member phone number	Member identification number (see identification card)

Employer or Group	Patient name	Relationship

AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)

I am authorizing LIBERTY Dental Plan to allow the following person to act on my behalf during the grievance/appeals

Representative last name	Representative first name	Representative phone number

Representative Signature	Member Signature

DENTAL OFFICE/PROVIDER INFORMATION (PLEASE PRINT)

I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from

Office number	Dental office name		Date of last visit

Dental office street address		City	State	ZIP Code

Dental office phone number		Name(s) of dental office staff involved (if known)

Appeals must be filed within 60 days from the date on your Notice of Adverse Benefit Determination (NABD)

Grievances can be filed at any time.

If you need help completing this form, call our Member Services Department at (833) 276-0850, or TTY 1-877-855- 8039, Monday through Friday 8:00 a.m. to 8:00 p.m. (ET). We can give you an interpreter at no cost, if you need one. You or someone you authorize have the right to review your case file at any time. We’ll give you copies free of charge.

SUMMARY OF GRIEVANCE OR APPEAL

Please share any information you have about your grievance or appeal. Please give us as many details as you can. If possible, please provide the dates, names and any treatment. If needed, you can attach an additional page.

Please share with us what outcome you would like to see from your grievance or appeal.

Member Signature

Date

PLEASE SEND COMPLETED SIGNED FORM TO:

Mail to

LIBERTY Dental Plan of Florida

Grievances and Appeals Department

P.O. Box 15149

Tampa, FL 33684

•Fax to LIBERTY’s Grievances and Appeals Department fax at (833) 250-1816

•Telephone by calling LIBERTY’s Member Services Department at (833) 276-0850, or TTY 1-877-855-8039

•Electronically by using the website online grievance filing process by visiting www.libertydentalplan.com/FLMedicaid .

•Emailing us at: FLGandA@libertydentalplan.com.

You will receive a letter confirming receipt of your grievance or appeal within 3 calendar days of receipt by LIBERTY.

You will receive a written resolution to your grievance within 30 calendar days of receipt by LIBERTY. You will receive a written resolution to your appeal within 20 calendar days of receipt by LIBERTY

You may request a copy of your records associated with your active grievance or appeal in writing to LIBERTY at the

address listed above.

FL G/A Form 2018.07.27

pg. 2

Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) complies with all applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability, or sex.

LIBERTY provides free aids and services to people with disabilities, and free language services to people whose primary language is not English, such as:

•Qualified interpreters, including sign language interpreters

•Written information in other languages and formats, including large print, audio, accessible electronic formats, etc.

If you need these services, please contact us at 1-833-276-0850 or TTY 1-877-855-8039.

If you believe LIBERTY has failed to provide these services or has discriminated on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with LIBERTY’s Civil Rights Coordinator:

Phone: 888-704-9833

TTY: 800-735-2929

Fax: 888-273-2718

Email: compliance@libertydentalplan.com

Online: https://www.libertydentalplan.com/About-LIBERTY-Dental/Compliance/Contact- Compliance.aspx

If you need help filing a grievance, LIBERTY’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

This information is available for free in other languages. Please contact our customer service number at 1- 833-276-0850 or TTY 1-877-855-8039 Monday through Friday from 8:00 a.m. to 8:00 p.m. (ET).

Esta información está disponible de forma gratuita en otros idiomas. Comuníquese con nuestro número de servicio al cliente al 1-833-276-0850 o TTY 1-877-855-8039, de lunes a viernes, de 8:00 a. m. a 8:00 p. m. (hora del este – ET).

Ransèyman sa a disponib gratis nan lòt lang. Kominike tanpri avèk sèvis kliyantèl la, swa nan 1-833-276- 0850 oswa nan TTY 1-877-855-8039, lendi pou vandredi ant 8:00 a.m. a 8:00 p.m. (ET).

Queste informazioni sono disponibili gratuitamente anche in altre lingue. Contattare il nostro servizio clienti al 1-833-276-0850 o via TTY al 1-877-855-8039, dal lunedì al venerdì dalle 8:00 alle 20:00 (ET).

La présente information est disponible gratuitement dans d’autres langues. Veuillez prendre contact avec notre service à la clientèle au 1-833-276-0850 ou par TTY au 1-877-855-8039, du lundi au vendredi, de 8 heures à 20 heures (L'heure de l'Est - HE).

FL G/A Form 2018.07.27

pg. 3