WRITTEN PROVIDER GRIEVANCE AND APPEAL FORM – NEVADA

Please use this form to help file a grievance or appeal with LIBERTY Dental Plan (LIBERTY). If you filed a verbal appeal with the Member Services Department, you must sign and complete this form and return it to LIBERTY within 15 days from the date you received it. If you are filing an appeal on behalf of a member, you must include signed authorization from the member.

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

Today’s date

 

 

 

 

 

Dental office street address

 

City

State

ZIP Code

 

 

 

 

 

Claim/TAR No.:

Denial reason(s):

 

 

 

 

 

 

 

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

 

 

 

 

MEMBER INFORMATION (PLEASE PRINT)

Member last name

Member first name

 

 

 

 

 

 

Member street address

City

State

ZIP code

 

 

 

 

Member phone number

Member identification number (see identification card)

 

 

 

 

Medicaid Providers may file a Grievance or Appeal within 90 days from the date of

LIBERTY’s initial decision.

If you need help completing this form, please contact Member Services at 1-866-609-0418

SUMMARY OF GRIEVANCE OR APPEAL

Please share any information you have about your grievance or appeal. Please ensure that you provide additional documentation to support your grievance or appeal. If needed you can attach an additional page.

Provider Signature

Date

*By providing LIBERTY with your signature, you are giving us your written permission to continue with the appeals process. If you do not sign and return this form, LIBERTY cannot continue with your appeal if it was received over the phone.

PLEASE SEND COMPLETED SIGNED FORM TO:

LIBERTY Dental Plan of Nevada

Quality Management Department

6385 S. Rainbow Blvd., Suite 200

Las Vegas, NV 89118

Or you may submit your grievance or appeal:

•By fax to LIBERTY’s Quality Management Department fax at (833) 250-1814

•Verbally by calling LIBERTY Dental Plan’s Member Services Department at toll-free number: (866) 609-0418, or TTY: (877) 855-8039

•By using our website online grievance filing process by visiting www.libertydentalplan.com.

You will receive a letter acknowledging receipt of your grievance or appeal within 5 calendar days of receipt by LIBERTY. You will receive a written resolution to your grievance and/or appeal within 30 calendar days of receipt by LIBERTY.

NV PDR Form 201711

pg. 2