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If the review of a claim denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a clinical judgment In applying the terms of the contract terms, Delta Dental shall consult with a dentist who has appropriate training and experience. The identity of such dental consultant is available upon request. Delta Dental will provide the Enrollee a written acknowledgement within five calendar days of receipt of the request for review. Delta Dental will make a written decision within 30 calendar days of receipt of the request for review. Delta Dental will respond, within three calendar days of receipt, to complaints involving severe pain and Imminent and serious threat to an Enrollee's health. An Enrollee may file a complaint with the Department of Managed Health Care after he or she has completed Delta Dental's grievance procedure or after he or she has been involved in Delta Dental's grievance procedure for 30 calendar days. An Enrollee may file a complaint with the Department Immediately in an emergency situation, which is one involving severe pain and/or Imminent and serious threat to the Enrollee's health. The California Department of Managed Health Care Is responsible for regulating health care service plans. If an Enrollee has a grievance against Delta Dental or the health plan, the Enrollee should first telephone Delta Dental at 800-765-6003 and use Delta Dental's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to an Enrollee. If help is needed with a grievance Involving an emergency, a grievance that has not been satisfactorily resolved by this health plan, or a grievance that has remained unresolved for more than thirty (30) calendar days, the Enrollee may call the department for assistance. An Enrollee may also be eligible for an Independent Medical Review (IMR). If eligible for an IMR, the IMR process will provide an Impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational In nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888 -HMO -2219) and a TDD line (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. If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the Enrollee may contact the U.S. Department of Employee Benefits Security Administration (EBSA) for further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is: U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue, N.W. Washington, D.C. 20210. 7.12 The Benefits that Delta Dental provides are limited to the applicable percentages of the Dentist's fees or allowances specified In Article 4. The Contractholder requires the Enrollee to pay the balance of any such fee or allowance, known as the "Enrollee Co -payment," as a method of sharing the costs of providing dental Beneflts between the Contractholder and Enrollees. If the Dentist discounts, waives or rebates any portion of the Enrollee Co -payment to the Enrollee, Delta Dental only provides as Benefits the Dentist's fees or allowances reduced by the amount that such fees or allowances are discounted, waived or rebated. 14 25C-66