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To submit a written Grievance, please use the link below to print and mail to LIBERTY Dental Plan, or complete the online form below.

Member Grievance and Appeal Form   -   Spanish Version

Please complete the Grievance Form with all related information.  LIBERTY considers a complaint and grievance as the same.  Please provide information regarding your complaint and your desired or proposed resolution to the complaint.  Your complaint will be considered by LIBERTY the next business day following successful submission of this Form by you. LIBERTY will send a written acknowledgement letter within five (5) days of receipt of this Form. LIBERTY will review your complaint and send you written notice of our determination within thirty (30) days of receipt of this Form. So that we may properly research and resolve this matter, a copy of your completed Grievance Form may be forwarded to the dentist(s) who provided treatment.
If you would like assistance in completing this form, please contact our Member Services Department at 1-866-609-0418.
Nevada Medicaid members are required to exhaust the Plan’s appeals process before you can request a State Fair Hearing. Appeals must be filed within 60 days from the denial letter.
You may request a fast resolution to your grievance or appeal. If we find that you meet the criteria, you will be provided a response within 72 hours.

Please only click Submit once