If your dental claim is denied or partly denied, you will receive written notice of the denial (referred to as an Explanation of Benefits, or EOB) directly from the Fund’s third party administrator (Delta Dental of Massachusetts) with a description of the process available to appeal the determination. If your vision claim is denied or partly denied, you will receive written notice of the denial directly from Davis Vision with a description of the process to appeal the determination.
Delta Dental is retained as a third-party administrator, responsible for processing and paying claims as per the Fund’s policies and procedures. Delta Dental is not able to approve any appeal regarding the application of Fund policy. Any appeal involving Fund policies may be sent directly to the MPE Fund office.
If your appeal involves the quality or other concern about the care delivered by a dental provider, a copy of your treatment records may be requested from the dental office and may be reviewed by a Dental Consultant and/or Analyst. Please note that the dental provider is solely responsible for the delivery of quality care. As per the Fund’s Legal Rights and Obligations, the Fund does not have any responsibility for the failure of a provider to fulfill these obligations.
Provided that you have exhausted all appeals available to you with Delta Dental of Massachusetts or Davis Vision, respectively, you or, if applicable, your beneficiary can request a review of your claim by the Fund.
This request for review should be sent to:
Board of Trustees
c/o Executive Director
Massachusetts Public Employees Fund
PO Box 3319
Peabody, MA 01961-3319
This request must be postmarked within sixty (60) days after you or, if applicable, your beneficiary received notice of the review of the claim. When requesting a review, please state the reason you or, if applicable, your beneficiary believe the claim was improperly denied and submit any data, questions or comments you or, if applicable, your beneficiary deem appropriate, including but not limited to:
- Member’s name and Subscriber Identification Number;
- Description of the problem, including relevant dates;
- Names of providers or others involved.
The Fund will investigate the problem and reply within forty-five (45) days. The Fund will do its best to resolve your appeal more quickly for services you are either receiving now or planning to receive.
The decision of the Board of Trustees, or the Executive Director acting on their behalf, on the disposition of the appealed claim is final.
Any appeal received after the required time limitations will not be considered for review.