YOUR RIGHTS  
UNDER DENTAL MANAGED CARE  
IF YOU DO NOT AGREE WITH THE DECISION MADE FOR YOUR DENTAL  
TREATMENT, YOU MAY FILE AN APPEAL. FILE THE APPEAL WITH YOUR  
DENTAL PLAN.  
HOW TO FILE AN APPEAL  
You have 60 days from the date of a Notice of Actionletter to file an appeal. If you  
are currently getting treatment and you want to continue getting treatment, you  
must ask for an appeal: within 10 days from the date this letter was postmarked or  
delivered to you; OR before the date your dental plan says services will stop. You must  
say that you want to keep getting treatment when you file the appeal.  
You can file an appeal by phone, in writing, or electronically:  
By phone: Contact LIBERTY Dental Plan’s Member Services Department  
between 8:00 am to 5:00 pm by calling 888-703-6999. If you cannot hear or  
speak well, please call 800-735-2929.  
In writing: Fill out an appeal form or write a letter and send it to:  
LIBERTY Dental Plan of California  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
Your dentist’s office will have appeal forms available. Your dental plan can also  
send a form to you.  
Electronically: Visit your health plan’s website. Go to www.libertydentalplan.com  
You may file an appeal yourself. You may have a relative, friend, advocate, dentist,  
doctor, or attorney file the appeal for you. You may send in any type of information you  
want your dental plan to review. A dentist who is different from the dentist who made the  
first decision will look at your appeal.  
Your dental plan has 30 days to give you an answer. At that time, you will get a “Notice  
of Appeal Resolution” letter. This letter will tell you what the dental plan has decided. If  
you do not get a letter within 30 days, you can:  
Ask for an “Independent Medical Review” (IMR) and an outside reviewer that  
is not related to the dental plan will review your case.  
Ask for a “State Hearing” and a judge will review your case.  
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Please read the section below for instructions on how to ask for an IMR or State  
Hearing.  
EXPEDITED APPEALS  
If you are in pain or think waiting 30 days will hurt your health or dental condition, you  
might be able to get an answer within 72 hours. When filing your appeal, say why  
waiting will hurt your health or dental condition. Make sure you ask for an “expedited  
appeal.”  
IF YOU DO NOT AGREE WITH THE APPEAL DECISION  
If you filed an appeal and received a “Notice of Appeal Resolution” letter telling you that  
your dental plan will still not provide the services, or you never received a letter telling  
you of the decision and it has been past 30 days, you may:  
Ask for an “Independent Medical Review” (IMR) and an outside reviewer that  
is not related to the dental plan will review your case.  
Ask for a “State Hearing” and a judge will review your case.  
You may ask for both an IMR and State Hearing at the same time. You may also  
ask for one before the other to see if it will resolve your problem first. For example, if  
you ask for an IMR first, but do not agree with the decision, you may still ask for a State  
Hearing later. However, if you ask for a State Hearing first, and the hearing has already  
taken place, you may not ask for an IMR. In this case, the State Hearing has the final  
say.  
You will not have to pay for an IMR or State Hearing.  
INDEPENDENT MEDICAL REVIEW (IMR)  
If you want an IMR, you must first file an appeal with your dental plan. If you do not hear  
from your dental plan within 30 days, or if you are unhappy with your dental plan’s  
decision, then you may request an IMR. You must ask for an IMR within 180 days from  
the date of the “Notice of Appeal Resolution” letter.  
You may be able to get an IMR right away without filing an appeal first. This is for  
cases where your health or dental function is in immediate danger. The paragraph  
below will provide you with information on how to request an IMR.  
The California Department of Managed Health Care (Department) is responsible for  
regulating dental managed care plans. If you received a Notice of Adverse Benefit  
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Determination” letter, you should first telephone your dental plan at and use your dental  
plan’s appeal process before contacting the Department. Utilizing your dental plan’s  
appeal procedure does not prohibit any potential legal rights or remedies that may be  
available to you. If you need help with an appeal involving an emergency, an appeal  
that has not been satisfactorily resolved by your dental plan, or an appeal that has  
remained unresolved for more than 30 days, you may call the Department for  
assistance. You may also be eligible for an Independent Medical Review (IMR). If you  
are eligible for an IMR, the IMR process will provide an impartial review of dental  
decisions made by a dental plan related to the medical necessity of a proposed service  
or treatment, and payment disputes for emergency or urgent medical services. The  
Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line  
(1-877-688-9891) for the hearing and speech impaired. The Department’s Internet  
Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms,  
and instructions online.  
STATE HEARING  
If you want a State Hearing, you must ask for one within 120 days from the date of the  
“Notice of Appeal Resolution” letter. You can ask for a State Hearing by phone or in  
writing:  
By phone: Call 888-703-6999. This number can be very busy. You may get a  
message to call back later. If you cannot speak or hear well, please call  
TTY/TDD 1-800-952-8349.  
In writing: Fill out a State Hearing form or send a letter to:  
California Department of Social Services  
State Hearings Division  
P.O. Box 944243, Mail Station 9-17-37  
Sacramento, CA 94244-2430  
You may send a State Hearing form or letter by Fax to (916) 651-5210 or  
(916) 651-2789.  
Be sure to include your name, address, telephone number, date of your “Notice  
of Appeal Resolution” (also known as a NAR), and the reason you want a State  
Hearing. If someone is helping you ask for a State Hearing, add their name,  
address, and telephone number to the form or letter. If you need an interpreter,  
tell us what language you speak. You will not have to pay for an interpreter. We  
will get you one.  
After you ask for a State Hearing, it could take up to 90 days to decide your case and  
send you an answer. If you think waiting that long will hurt your health or dental function,  
you might be able to get an answer within 3 working days.  
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Ask your dentist or dental plan to write a letter for you. The letter must explain in detail  
how waiting for up to 90 days for your case to be decided will seriously harm your health  
or your dental function. Then, make sure you ask for an “expedited hearing” and  
provide the letter with your request for a hearing.  
You may speak at the State Hearing yourself. You may have a relative, friend,  
advocate, dentist, doctor, or attorney speak for you. If you want another person to speak  
for you, then you must tell the State Hearing office that the person is allowed to speak  
on your behalf. This person is called an “authorized representative.”  
LEGAL HELP  
You may be able to get free legal help. Call the Health Consumer Center of Los  
Angeles at 800-896-32034 You may also call the local Legal Aid Society in your county  
at 888-804-3536.  
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