Attn: Appeals Coordinator P.O. Box 75983 Seattle, WA 98175-0983 For oral appeals, please call Uniform Dental Plan Customer Service Department at 1-800-537-3406. You may include any written comments, documents or other information that you believe supports your claim. DDWA will review your claim and make a determination within 30 days of receiving your request and send you a written notification of the review decision. Upon request, you will be granted access to and copies of all relevant information used in making the review decision. Informal reviews of wholly or partially denied claims are conducted by persons not involved in the initial claim determination. In the event the review decision is based in whole or in part on a dental clinical judgment as to whether a particular treatment, drug or other service is experimental or investigational in nature, DDWA will consult with a dental professional advisor. Appeals Committee If you are dissatisfied with the outcome of the informal review, you may request that your claim be reviewed formally by the DDWA Appeals Committee. This Committee includes only persons who were not involved in either the original claim decision or the informal review. Your request for a review by the Appeals Committee must be made within 90 days of the post-marked date of the letter notifying you of the informal review decision. Your request should include the information noted above plus a copy of the informal review decision letter. You may also submit any other documentation or information you believe supports your case. The Appeal Committee will review your claim and make a determination within 60 days of receiving your request or within 20 days for Experimental/Investigational procedure appeals and send you a written notification of the review decision. Upon request, you will be granted access to and copies of all relevant information used in making the review decision. In the event the review decision is based in whole or in part on a dental clinical judgment as to whether a particular treatment, drug or other service is experimental or investigational in nature, DDWA will consult with a dental professional advisor. The decision of the Appeals Committee is final. If you disagree with this the outcome of your appeal and you have exhausted the appeals process provided by the Uniform Dental Plan, there may be other avenues available for further action, including legal action brought on your behalf. If so, these will be provided to you in the final decision letter. Authorized Representative An enrollee may authorize another person to represent them and with whom they want DDWA to communicate regarding specific claims or an appeal. The authorization must be in writing, signed by the enrollee, and include all the information required in an appeal. (An assignment of benefits, release of information, or other similar form that the enrollee may sign at the request of their health care provider does not make the provider an authorized representative.) The enrollee can revoke the authorized representative at any time, and enrollees can authorize only one person as their representative at a time. Your Rights and Responsibilities At DDWA our mission is to provide quality dental benefit products to employers and employees throughout Washington through a network of more than 3,400 participating dentists. We view our benefit packages as a partnership between DDWA, our subscribers and our participating members’ dentists. All partners in this process play an important role in achieving quality oral health services. We would like to take a moment and share our views of the rights and responsibilities that make this partnership work. 2024-01-03000-BB 37 LG PPOL 20240101