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Get Dentaquest Provider Appeal Form

DentaQuest. com Call Toll Free 800-508-6775 Signature Return Completed Forms To Date Attention C G Department 11044 Research Blvd Building D Suite D-400 Austin TX 78759 Fax XXX-XXX-XXXX Call toll free 800-508-6775 Within 5 days of receiving an appeal request we will send you a confirmation letter. Member Toll Free 800-508-6775 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 City State Zip Please explain your appeal Please sign to allow DentaQuest TX HHSC Dental Services to obtain any medical records and/or information needed to research your appeal. Stratum Executive Center 11044 Research Blvd Building D Suite D-400 Austin TX 78759 www. DentaQuest TX HHSC Dental Services Member Appeal Form You have the right to request an appeal if you are not happy with the outcome of your complaint* If you have any questions or need help filling out this form please contact our Customer Service Call Center. This letter will describe the appeal process and your rights. A decision will be reached on your appeal within 30 days. Emergency appeals will be completed first but no later than 1 day after receipt. At least 5 days before the appeal panel meets you will receive a letter. The letter will contain a listing of All materials we gave to the appeal panel* The specialty of the providers contacted during the investigation* The name and affiliation of the appeal panel* The final decision letter will provide The clinical and/or contract term s the decision was based on* Toll-free telephone number and address of the Texas Department of Insurance. You can file a complaint with the Texas Department of Insurance TDI at any time. Texas Department of Insurance P. O. Box 149091 Austin Texas 78714-9091 800-252-3439 Web site www. tdi. state. tx. us for instructions and complaint forms E-mail ConsumerProtection tdi. This letter will describe the appeal process and your rights. A decision will be reached on your appeal within 30 days. Emergency appeals will be completed first but no later than 1 day after receipt. At least 5 days before the appeal panel meets you will receive a letter. Emergency appeals will be completed first but no later than 1 day after receipt. At least 5 days before the appeal panel meets you will receive a letter. The letter will contain a listing of All materials we gave to the appeal panel* The specialty of the providers contacted during the investigation* The name and affiliation of the appeal panel* The final decision letter will provide The clinical and/or contract term s the decision was based on* Toll-free telephone number and address of the Texas Department of Insurance. The letter will contain a listing of All materials we gave to the appeal panel* The specialty of the providers contacted during the investigation* The name and affiliation of the appeal panel* The final decision letter will provide The clinical and/or contract term s the decision was based on* Toll-free telephone number and address of the Texas Department of Insurance. You can file a complaint with the Texas Department of Insurance TDI at any time. Texas Department of Insurance P.

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