Appeals, Independent Medical Review and State Hearings for dental managed care
Explains members' rights and step-by-step procedures to file appeals, request continuation of benefits during appeals, pursue independent medical review (IMR), and request state-level hearings for dental managed care programs under Knox‑Keene.
No material clinical or coverage changes in this revision.
Appeals, IMR and State Hearing Criteria
Appeals, IMR and State Hearing procedural criteria
Procedural steps, timelines, member entitlements, and conditions for continuation of benefits and external review.
ALL of the following
To qualify for continuation of benefits (benefits while appeal is pending)
- Member requests the appeal within 10 days of the Notice of Action.
- OR the member requests the appeal before the program changes the service(s).
- If the member misses the 10‑day window or does not request the appeal before the change, the member still has 60 days to file an appeal but is not eligible for continuation of benefits while the appeal is pending.
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