MEMBER GRIEVANCE AND APPEAL FORM – NEVADA
You can use this form to file a grievance or appeal with LIBERTY Dental Plan
(LIBERTY).You can also use this form to give LIBERTY more information to help review
your case. If you filed an appeal over the telephone, you can also complete this form
and mail back to LIBERTY. This is optional. We will review your case without a written
appeal.
MEMBER INFORMATION (PLEASE PRINT)
Member last name
Member first name
Today’s date
Member street address
City
State
ZIP code
Member phone number
Member identification number (see identification card)
Employer or Group
Patient name
Relationship
AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)
I am authorizing LIBERTY Dental Plan to allow the following person to act on my behalf during the grievance/appeals
Representative last name
Representative first name
Representative phone number
Representative Signature
Member Signature
DENTAL OFFICE/PROVIDER INFORMATION (PLEASE PRINT)
I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from
Office number
Dental office name
Date of last visit
Dental office street address
City
State
ZIP Code
Dental office phone number
Name(s) of dental office staff involved (if known)
Appeals must be filed within 60 days from
the date on your Notice of Action
(NOA)
Grievances can be filed at any time.
NV G/A Form 2019.03.06 pg. 2
If you need help completing this form, call our Member Services Department at 1-866-609-0418, Monday through
Friday 8:00 a.m. to 5:00 p.m.. If you cannot hear or speak well, please call 1-800-952-8349. If you need an
interpreter, we will get you one at no cost. You or someone you authorize have the right to review your case file at
any time. We’ll give you copies free of charge.
Member Signature
Date
PLEASE SEND COMPLETED SIGNED FORM TO:
Mail to:
LIBERTY Dental Plan of Nevada
Grievances and Appeals Department
P.O. Box 401086
Las Vegas, NV 89140
• Fax to LIBERTY’s Grievances and Appeals Department at 1-833-250-1814
• Telephone by calling LIBERTY’s Member Services Department at:
1-866-609-0418, or TTY: 1-877-855-8039
• Electronically by using our website online grievance filing process by
visiting www.libertydentalplan.com/NVMedicaid.
• Emailing us at: NVGandA@libertydentalplan.com
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.
You may request a copy of your records associated with your active grievance or appeal in writing to LI BERTY at the
address listed above.
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.
