SUMMARY OF GRIEVANCE OR APPEAL
Please share any information you have about your grievance or appeal. Please give us as many details as you can, if
possible please provide the dates, names and any treatment. If needed you can attach an additional page.
Please share with us how you would like to see your grievance or appeal resolved.
By providing LIBERTY with your signature, you are giving us your written permission to continue with the appeals process.
If you do not sign and return this form, LIBERTY cannot continue with your appeal if it was received over the phone.
PLEASE SEND COMPLETED SIGNED FORM TO:
Or you may submit your grievance or appeal:
LIBERTY Dental Plan of Nevada
Quality Management Department
By fax to LIBERTY’s Quality Management Department fax at (949) 270-0109
Verbally by calling LIBERTY Dental Plan’s Member Services Department at toll-free
number: (866) 609-0418, or TTY: (877) 855-8039
385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
You will receive a letter acknowledging receipt of your grievance or appeal within 5 calendar days of receipt by LIBERTY.
You will receive a written resolution to your grievance or appeal within 30 calendar days of receipt by LIBERTY.
NV G/A Form 20170917