Third Party Payer Complaint Form

1. Please utilize this form to report problems with third party payers.

This form is only intended for use by dentists and dental office staff. The information provided on this form is for data collection and trending purposes only. No individual follow up is intended.

Please record one complaint occurrence per form. At the end of the form, you will be asked if you would like to submit information on additional complaints.

Question Title

* 1. Enter Today's Date

Today's Date

Date

Question Title

* 2. Enter Dentist's Name

Question Title

* 3. Third Party Payer Name

Anthem BC/BS

United Health Care

CIGNA

ConnectiCare

Delta Dental

Met Life

Guardian

Health Plex

Self Funded Plan

Other (or, indicate state for Delta Dental above)

Question Title

* 4. Is the Dentist Contracted with the Plan?

Yes

Question Title

* 5. If your complaint is about a specific claim(s), how was the claim filed?

Paper

Electronic

Question Title

* 6. What type of complaint or problem applies to you? (check all that apply)

Coordination of Benefits

Explanation of Benefits (EOB) language

Downcoding (changed code to a less complex or lower cost procedure)

Bundling (combining distinct procedures that results in a reduced benefit)

Review by non-dentist

Utilization review (a system to evaluate procedure utilization frequency/plan abuse)

Delayed payment

Denial of claim or pre-authorization

Lost claims, x-rays or other documentation by carrier

Extensive or additional documentation requested

Interference with the doctor-patient relationship

Inability to reach an authoritative individual within insurance company

Other (please specify)

Question Title

* 7. Please give a brief description of the problem.

Question Title

* 8. May the CSDA Contact you if we require additional information?

Yes

phone or email

Question Title

* 9. Would you like to submit information regarding another complaint?

Yes, please!

No thanks, not at this time.