(Insurance Company/HMO)
(Date)
XXXX XXXXX
XXXX XXXX XXXXX
XXX XXXXX, XX XXXXX
Member Name:
Member Number:
Provider Name:
Service: Midface Reconstruction and Oral Surgical Splint
Referral Number: XXXXXXXXXXXX. XXXXXXXXXXXX
Dear XXXX:
XXX has received and is currently processing your written request for review before the XXX Grievance Committee. Your case will be reviewed at the next meeting as follows:
(WHEN)
(WHERE)
Numerous cases are heard at a grievance hearing. We will contact you to set a time for your case to be heard. If you cannot attend in person, you may attend via telephone conference.
As an XXX member, you have the option of representing yourself or your legal dependent. If you choose to assign a third party to represent you or your dependent, or if there is another person who simply wants to attend the meeting with you, please provide XXX this information prior to the hearing date.
If you have any questions, please feel free to call Member Services at (XXX) XXX-XXXX Monday - Friday, 8 am to 5 pm. If you are outside the XXX XXXXX area, please call our toll-free number (800) XXX-XXXX.
Sincerely,
XXXXXXX XXXXX, CR Grievance Coordinator
Customer Response and Resolution Department
cc: Doctor
Notice of Grievance Committee Hearing
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This cleftAdvocate page was last updated March 25, 2014
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