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  • Dentaquest Appeal Form

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G out this form, please contact our Customer Service Call Center. Member Toll Free: 800-516-0165 Provider Toll Free: 800-896-2374 ! Member Person filing appeal Type of appeal would you like to file ! Written Hearing Impaired: TTY 800-855-2880 ! Provider ! In-Person ! Member Name Provider Name Member Identification Number Provider License Number Telephone Number National Provider Identifier Address Telephone Number City Address State Zip City State Zip Please explain your appe.

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If you decide to file an appeal, the Maryland Attorney General's Health Education and Advocacy Unit will assist you, free-of-charge, in filing your appeal. The Health Education and Advocacy Unit may be reached toll-free at 1-877-261-8807.

If you need help outside Molina If you want to talk to someone outside Molina about the problem, you can contact: For help with a grievance or appeal: HMO Enrollment Specialist at 1-800-291-2002.

The request for an appeal must be made no more than 60 days after you receive notice of services being denied, limited, reduced, delayed, or stopped. If you disagree with your HMO's decision about your appeal, you may request a fair hearing with the Wisconsin Division of Hearing and Appeals.

If you're a health care provider or HMO, call Provider Services at 800-947-9627.

individuals must contact the Medicaid Hotline at 1-800-252-8263. staff must contact the Third-Party Resource (TPR) Unit at 1-800-846-7307.

How do I do it? An appeal may be filed orally by phone, fax it, or in writing (mail or fax). This needs to be within 60 calendar days of when you get the notice of adverse benefit determination (denial notice). Call Peach State toll free at 1-800-704-1484, TTY/TDD 1-800-255-0056.

To receive consideration, the request must be submitted within 180 days from the date the backdated enrollment was added to the member's enrollment information.

An appeal is a written request by a practitioner/organizational provider to change: An adverse reconsideration decision. An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria. An adverse initial utilization review decision.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232