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PEF Dental Plan

This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.

Grievances and Appeals

Grievances and Appeals. If you do not agree with GHI's disposition of a claim or any other determination made by GHI, you or your designated representative may ask GHI to reconsider its determination.

  1. Grievances. If you do not agree with a determination made by GHI other than a denial of coverage on the basis that services are not medically necessary or are experimental or investigational, you or your designated representative may file a grievance with the GHI Subscriber Relations Department asking GHI to reconsider its decision. Your grievance should include your GHI identification number, claim number(s) and any other information you wish GHI to consider. A written decision will be sent to you by GHI. It will explain GHI's basis of upholding or changing the original disposition of the claim. If you do not agree with GHI's decision, you may file another grievance.
  2. Please send your written grievance to:

    GHI - Attn: NYS Customer Service
    P.O. Box 12365
    Albany, NY 12212-2365

    or call 1-800-947-0101

  3. Internal Appeals. If GHI has denied your claim for covered services on the basis that the services are not medically necessary or they are experimental or investigational in nature, you or your designated representative may file an appeal with GHI. Such an appeal may be filed either by telephone or in writing. It must be filed on or before forty-five (45) days from the date you receive notice of GHI's determination and the information needed for you to file the appeal. When filing an appeal, please include your GHI identification number. Also include all applicable claim numbers as well as any medical data and comments in support of your appeal.
  4. GHI will acknowledge receipt of your appeal in writing within fifteen (15) days of receipt. A clinical peer reviewer other than the clinical peer reviewer who made GHI's initial decision will review the appeal. GHI will make a decision on your appeal within sixty (60) days of receipt of the appeal and any information needed for GHI to conduct a full and fair review. GHI will notify you of its decision within two (2) business days of GHI's decision. The notice will include the reason for GHI's decision. If GHI upholds its denial on the appeal, then the notice will also include the clinical reasons for the decision. The notice will also include notice of your right to file an external appeal, together with a description developed jointly by the New York State Department of Insurance and Health of the external appeal process. If GHI fails to make a decision on your appeal within the timeframes above, the decision will be deemed to be a reversal of GHI's denial.

    To file a verbal appeal, please call toll free:

    1-800-947-0101

    To file a written appeal, please write to:

    GHI – Attn: NYS Customer Service
    P.O. Box 12365
    Albany, NY 12212-2365

  5. Expedited Internal Appeals. GHI offers an expedited appeal process in certain cases. Expedited appeals may be taken in cases that involve continued or extended dental services, procedures or treatments; requests for additional services for a person undergoing a course of continued treatment; and cases in which the Dentist or Provider believes an immediate appeal is warranted except any retrospective determination. GHI will provide reasonable access to its clinical peer reviewer within one (1) business day of GHI's receipt of notice of the filing of an expedited appeal. GHI will render a decision within two (2) business days of GHI's receipt of the expedited appeal and any information needed for GHI to conduct a full and fair review. GHI will notify you of its decision within twenty-four (24) hours of GHI's decision. The notice will include all of the same information provided with notices of decision on a standard internal appeal.
  6. To file an expedited appeal, please call GHI toll free: 1 (888) 906-7668. Expedited appeals that do not produce a result satisfactory to you or your provider may be further appealed through the standard or external appeal process.

External Appeals

Your Right to an External Appeal

Under certain circumstances, you have the right to an external appeal of a denial of coverage. Specifically, if GHI has denied coverage on the basis that the service is not medically necessary, you may appeal to an external appeal agent, an independent entity certified by the State of New York to conduct such appeals.

Your Right to Appeal a Determination that a Service is not Medically Necessary

If GHI has denied coverage on the basis that the service is not medically necessary, you may appeal to an external appeal agent if you satisfy the following two (2) criteria:

  • The service, procedure or treatment must otherwise be a covered service under this Certificate; and
  • You must have received a final adverse determination through GHI's internal appeal process and GHI must have upheld the denial or you and GHI must agree in writing to waive any internal appeal.

Your Right to Appeal a Determination that a Service is Experimental or Investigational

If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following two (2) criteria:

  • The service must otherwise be a covered service under this Certificate; and
  • You must have received a final adverse determination through GHI's internal appeal process and GHI must have upheld the denial or you and GHI must agree in writing to waive any internal appeal.

In addition, your attending physician must certify that you have a life threatening or disabling condition or disease. A "life-threatening condition or disease" is one that, according to the current diagnosis of your attending physician, has a high probability of death. A "disabling condition or disease" is any medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or can be expected to last for a continuous period of not less than twelve (12) months, which renders you unable to engage in any substantial gainful activities. In the case of a child under the age of eighteen, a "disabling condition or disease" is any medically determinable physical or mental impairment of comparable severity.

Your attending physician must also certify that your life-threatening or disabling condition or disease is one for which standard health services are ineffective or medically inappropriate or one for which there does not exist a more beneficial standard service or procedure covered by GHI or one for which there exists a clinical trail (as defined by law).

In addition, your attending physician must have recommended one of the following:

  • A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to you than any standard covered service (only certain documents will be considered in support of this recommendation — your attending physician should contact the State in order to obtain current information as to what documents will be considered acceptable): or
  • A clinical trial for which you are eligible (only certain clinical trials can be considered).

For the purposes of this section, your attending physician must be a licensed, board-certified or board eligible physician qualified to practice in the area appropriate to treat your life-threatening or disabling condition or disease.

The External Appeal Process

If, through GHI's internal appeal process, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have forty-five (45) days from receipt of such notice to file a written request for an external appeal. If you and GHI have agreed in writing to waive any internal appeal, you have forty-five (45) days from receipt of such waiver to file a written request for an external appeal. GHI will provide an external appeal application with the final adverse determination issued through the GHI's internal appeal process or its written waiver of an internal appeal.

You may also request an external appeal application from New York State at (800) 400-8882. Submit the completed application to State Department of Insurance at the address indicated on the application. If you satisfy the criteria for an external appeal, the State will forward the request to a certified external appeal agent.

You will have an opportunity to submit additional documentation with your request. If the external appeal agent determines that the information you submit represents a material change from the information on which GHI based its denial, the external appeal agent will share this information with GHI in order for it to exercise its right to reconsider its decision. If GHI chooses to exercise this right, GHI will have three (3) business days to amend or confirm its decision. Please note that in the case of an external expedited appeal (described below), GHI does not have a right to reconsider its decision.

In general, the external appeal agent must make a decision within thirty (30) days of receipt of your completed application. The external appeal agent may request additional information from you, your physician or GHI. If the external appeal agent requests additional information, it will have five (5) additional business days to make its decision. The external appeal agent must notify you in writing of its decision within two (2) business days.

If your attending physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to your health, you may request an expedited external appeal. In that case, the external appeal agent must make a decision within three (3) days of receipt of your completed application. Immediately after reaching a decision, the external appeal agent must try to notify you and GHI by telephone or facsimile of that decision. The external appeal agent must also notify you in writing of its decision.

If the external appeal agent overturns GHI's decision that a service is not medically necessary or approves coverage of an experimental or investigational treatment, GHI will provide coverage subject to the other terms and conditions of this Certificate. Please note that if the external appeal agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, GHI will only cover the costs of services required to provide treatment to you according to the design of the trial. GHI shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be covered under this Certificate for non-experimental or non-investigational treatments provided in such clinical trial.

The external appeal agent's decision is binding on both you and GHI. The external appeal agent's decision is admissible in any court proceeding.

GHI will charge you a fee of $50 for an external appeal. The external appeal application will instruct you on the manner in which you must submit the fee. GHI will also waive the fee if GHI determines that paying the fee would pose a hardship to you. If the external appeal agent overturns the denial of coverage, the fee shall be refunded to you.

Your Responsibilities

It is your responsibility to initiate the external appeal process. You may initiate the external appeal process by filing a completed application with the New York State Department of Insurance. If the requested service has already been provided to you, your physician may file an external appeal application on your behalf, but only if you have consented to this in writing.

Under New York State law, your completed request for appeal must be filed within forty-five (45) days of either the date upon which you receive written notification from GHI that it has upheld a denial of coverage or the date upon which you receive a written waiver of any internal appeal. GHI has no authority to grant an extension of this deadline.