FYI

At Delta Dental, ensuring timely and appropriate access to care is a top priority. Our key appointment standards and protocols are designed to help deliver consistent, quality care for all patients.
 

Appointment standards

PPO

• Non-urgent initial visits or visits for routine care will be available within 36 business days of the enrollee’s request.
• Preventive dental care appointments, such as hygiene appointments, will be available within 40 business days of the enrollee’s request.
• Dental offices should have an effective system for following up on canceled, broken and missed appointments in place to ensure timely rescheduling of a new appointment in a manner that’s appropriate for the patient’s health care needs. 
• Make sure to have mechanisms in place to remind the patient of their upcoming appointment.
   

DHMO

• Triage and/or palliative care, if needed, must be available 24 hours per day, seven days per week for:
  • Severe dental/oral pain, bleeding or swelling; or
  • Dental emergencies that risk life or disability without timely professional care
• If the patient arrives on time for scheduled appointments, waiting time before being seated in the operatory should be no more than 30 minutes.
• The first available appointment time frames are:
  • New patient: within four weeks
  • Routine follow-up: within four weeks
  • Hygiene: within six weeks
     

Emergency and after-hours protocols

• An active after-hours mechanism such as an answering machine, answering service, a cell phone or a pager, should be available for 24-hour/7-day contact with instructions regarding how patients may obtain urgent or emergency care. This includes, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care.
• Urgent care should be provided within 72 hours from the initial diagnosis, or less, depending on the individual needs of the patient and the generally accepted standards of dentistry.
• DHMO: If an assigned facility will be unavailable to provide emergency access 24 hours per day, seven days per week, the Contract General Dentist must make alternative arrangements in advance ensuring that emergency care will be available.
   

Referrals and pre-authorizations

• Consultations and referrals must be noted in the treatment record, including the name and contact information of the provider the consultation or referral is being sent to. The patient must also be provided with this information.
• Delta Dental may require selected providers to obtain prior authorization for some or all dental services. Providers may be required to submit additional X-rays and/or documentation to substantiate the need for the treatment requested or to demonstrate that the quality of the treatment performed is consistent with generally accepted standards of care. Providers may be randomly selected to obtain prior authorization or for special claims review as a result of utilization review, or after consideration of other reasonable circumstances. Written notification will be sent to all selected providers at least 30 days in advance of prior authorization or special claims review requirements.
• Always strive to close the referral loop: Confirm follow-up, share records and maintain communication with specialists.
   

Key reminders for providers

✔ Keep your provider directory info up to date.
✔ Maintain open lines for scheduling and patient inquiries.
✔ Post clear emergency instructions in office and online.
✔ Document all referrals and treatment decisions thoroughly.