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The appeal must be submitted within 180 days of the claim processing date. A final benefit determination is issued within 14 days, and may require up to an additional 16 days after receipt for a total of 30 days. 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The request to have a denied or modified claim reviewed must be submitted within 180 days from the date the claim was processed. A final benefit determination will be made within 14 days, and may take up to an additional 16 days for a total of 30 days, following receipt of this appeal.  \nAppeal can be mailed to:  \nDelta Dental of Washington  \nAttn: Appeals Coordinator  \n720 S Washington Street  \nColville, WA 99114  \nFax: 509-685-6662 [Email:](Email: memberappeals@deltadentalwa.com)[ memberappeals@deltadentalwa.com](Email: memberappeals@deltadentalwa.com)  \n[Complete the following information in full.](Complete the following information in full.)  \nMember ID number:   Subscriber’s name:   Patient’s name:   Day time phone number:    \nSubscriber’s mailing address:  \n____________________________________________________________________________________  \n____________________________________________________________________________________  \nClaim number and/or date of service:   Reason for appeal (please elaborate on the situation you are appealing, include any symptoms you were experiencing):  \nIf additional space is needed, please attach another sheet.  \nSignature:   Date:   Print Name:   Relationship to subscriber:    \nNondiscrimination and Language Assistance Services  \nDelta Dental of Washington complies with applicable Federal and Washington State civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity or sexual orientation.  \nDelta Dental of Washington does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity or sexual orientation.  \nWe will provide free aids and services to people with disabilities to assist in communicating effectively with DDWA staff, such as:  \n⧫ Qualified sign language interpreters  \n⧫ Written information in other formats (large print, audio, accessible electronic formats, other formats)  \nWe will provide free language services to assist in communicating effectively with DDWA staff for people whose primary language isnot English, such as:  \n⧫ Qualified interpreters  \n⧫ Information written in other languages  \nIf you need these services, contact Delta Dental of Washington’s Customer Service at: 800-554-1907. If you need translation or interpreter assistance at your dental provider’s office, please contact their staff. The cost for translations and interpreter services for communication between you and your provider are not covered by DDWA.  \nIf you believe that Delta Dental of Washington has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity or sexual orientation, you can file a grievance with our Compliance/Privacy Officer who may be reached as follows: PO Box 75983 Seattle, WA 98175, Ph: 800-554-1907, TTY: 800-833- 6384, Fx: 206 729-5512 or by email at: [Compliance@DeltaDentalWA.com](Compliance@DeltaDentalWA.com. You)[. You](Compliance@DeltaDentalWA.com. You) can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Compliance/Privacy Officer is available to help you.  \nYou can also file a civil rights complaint with:  \n⧫ The U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at [https://ocrportal.hhs.gov/ocr/portal/lobby.jsf](https://ocrportal.hhs.gov/ocr/portal/lobby.jsf), or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201, 1-800-368- 1019, 800-537-7697 (TDD) . Complaint forms are available at [http://www.hhs.gov/ocr/office/fi](http://www.hhs.gov/ocr/offic","cbCailXmwSccq9Sw","https://ap.wps.com/l/cbCailXmwSccq9Sw","pdf",678202,"English","# Appeal submission timeline\n# How to mail or contact the appeals coordinator\n# Subscriber and patient information\n# Claim details and reason for appeal\n# Signature and submission fields\n# Nondiscrimination and language assistance services","[{\"question\":\"How long do I have to submit an appeal after my claim is processed?\",\"answer\":\"Submit the request for review within 180 days from the date the claim was processed.\"},{\"question\":\"How long will Delta Dental of Washington take to make a final decision on an appeal?\",\"answer\":\"A final benefit determination will be made within 14 days, and may take up to an additional 16 days for a total of 30 days after receipt of the appeal.\"},{\"question\":\"What information is required to complete the appeal form?\",\"answer\":\"The form requests member ID number, subscriber and patient names, day time phone number, subscriber mailing address, claim number and/or date of service, reason for appeal, plus your signature, date, print name, and relationship to the subscriber.\"}]","Subscriber Appeals Form - Complete the Appeal Information | PDF",1789564108]