Federal laws say that you must use LIBERTY’s internal appeal process before you can request a state fair hearing. You are not losing your state fair hearing rights. After you have completed LIBERTY’s internal appeal process and you receive a decision that is not fully in your favor, you can request a state fair hearing. Information on how to request state fair hearing can be found on the Your Rights Document included with your Notice of Appeal Resolution letter.

To submit a written Grievance (Complaint) or Appeal to LIBERTY Dental Plan (LIBERTY), please complete the only form below or download the pdf version in the language preferred. You can also ask your dental office for a form or print a form from our website and mail it to the address below. You can also call LIBERTY’s Member Services Department to submit a complaint or appeal over the telephone.

LIBERTY Dental Plan

Grievances and Appeals Department

P.O. Box 26110

Santa Ana, CA 92799-6110

Phone: 1-888-703-6999

Fax: 1-833-250-1814

Please provide information regarding your complaint or appeal and your desired outcome.  Your complaint or appeal will be reviewed by LIBERTY the next business day following successful submission of this Form by you. You will get a letter from us within five (5) days letting you know we received your request.  If you would like to add anything to your case, please call us right away. We will review your complaint or appeal and send you a letter of our decision within thirty (30) days from the date we received your request. You can ask for an extension if you feel more time is needed. We can also ask for an extension if it is in your best interest, but we will not take more than fourteen (14) additional days to give you a response.

If you think waiting thirty (30) days could put your health or life at risk, you can ask for a fast review. If LIBERTY finds a fast review is needed, we will give you an answer within 72 hours from the time we received your request.

If you need help with this form or if you have questions, please contact us. We are here to help!

• Oklahoma Appeal Request Form English
• Oklahoma Appeal Request Form Spanish