In no event may DMO retaliate against a contract holder or covered person because that person has filed a complaint against DMO or appealed a decision made by DMO, nor may DMO retaliate against a general or specialty dentist who has filed a complaint against or appealed a decision by DMO.

When you notify us orally or in writing of a complaint, we will, no later than the fifth business day after the date we receive the complaint, send you a letter acknowledging the complaint . If the complaint was received orally, we will send you a one-page complaint form clearly stating that the complaint form must be returned to us for prompt resolution.

After we receive the written complaint or one-page complaint form from you, we will investigate and send you a letter with the resolution. The total time for acknowledging, investigating and resolving your complaint will not exceed 30 calendar days after the date we receive your complaint.

Your complaint concerning an emergency will be resolved in one business day of receipt of your complaint.  The investigation and resolution shall be concluded in accordance with the dental immediacy of the case.

You may use the Appeals Process to resolve a dispute regarding the resolution of your complaint.

Appeals to the DMO

If the complaint is not resolved to your satisfaction, you have the right either to appear in person before a complaint appeal panel where you normally receive dental services, unless another site is agreed to by you, or to address a written appeal to the complaint appeal panel. We will complete the appeals process no later than the 30th calendar day after the date we receive the request for appeal.

We will send an acknowledgment letter to you no later than the fifth business day after the date we receive the request for appeal.

We will appoint members to the complaint appeal panel, which will advise us on the resolution of the dispute. The complaint appeal panel shall be composed of an equal number of DMO staff, Dentists and enrollees.

No later than the fifth business day before the scheduled meeting of the panel, unless you agree otherwise, we will provide to you or your designated representative:

1. any documentation to be presented to the panel by DMO staff;
2. the specialties of any dentists consulted during the investigation;
3. the name and affiliation of each of the DMO representatives on the panel.

1. appear in person before the complaint appeal panel;
2. present alternative expert testimony;
3. request the presence of and question any person responsible for making the prior determination that resulted in the appeal.

Investigation and resolution of appeals relating to ongoing emergencies will be concluded in accordance with the dental immediacy of the case but in no event to exceed one business day after your request for appeal.

Due to the ongoing emergency and at your request, we will provide, in lieu of a complaint appeal panel, a review by a Dentist who has not previously reviewed the case and is of the same or similar specialty as typically manages the dental condition, procedure, or treatment under discussion for review of the appeal. 

The dentist reviewing the appeal may interview you or your designated representative and shall render a decision on the appeal. Initial notice of the decision may be delivered orally if followed by written notice of the determination within three days.

Notice of our final decision on the appeal must include a statement of the specific dental determination, clinical basis, and contractual criteria used to reach the final decision.

Filing Complaints with the Texas Department of Insurance

Any person, including persons who have attempted to resolve complaints through the DMO complaint system process and who are dissatisfied with the resolution, may report an alleged violation to the Texas Department of Insurance, P.O. Box 149091, Austin, Texas 78714-9091.

The commissioner will investigate a complaint against the DMO to determine compliance within 60 days after the Texas Department of Insurance receives the complaint and all information necessary for the department to determine compliance. The commissioner may extend the time necessary to complete an investigation in the event any of the following circumstances occur:

1. additional information is needed;
2. an on-site review is necessary;
3. the DMO, the dentist, or you do not provide all documentation necessary to complete the investigation; or
4. other circumstances beyond the control of the department occur.