Description of Grievance
Describe your grievance in detail. Please provide the dates, names and treatment that are the subject of your grievance. Attach additional pages, if necessary.
What is your desired resolution to your concern(s)?
MEMBERS OF LIBERTY DENTAL PLAN ONLY - PLEASE SEND COMPLETED FORM TO:
Or you may submit your grievance:
LIBERTY Dental Plan
Attention: Quality Management Department
P.O. Box 26110
By fax to LIBERTY’s Member Services Department fax at (949) 223-0011, or
Santa Ana, CA 92799-6110
You will receive a letter acknowledging receipt of your grievance within five (5) calendar days of receipt by LIBERTY.
You will receive a written resolution to your grievance within thirty (30) calendar days of receipt by LIBERTY.
IF YOUR HEALTH PLAN CONTRACTS WITH LIBERTY TO PROVIDE YOUR DENTAL BENEFITS:
You should contact your Health Plan for information on how to submit a grievance or appeal, or you may contact LIBERTY Dental Plan.
When contacting LIBERTY to inquire on how to submit a grievance or appeal, please call (888) 703-6999.
If your Health Plan allows, LIBERTY may accept your grievance or appeal verbally.
If your Health Plan allows, LIBERTY may accept this completed form as your written grievance or appeal.
A LIBERTY Member Services Representative will let you know if your Health Plan requires that you contact them directly to file a grievance or appeal regarding your
dental treatment and/or services.