FYI

When key clinical details are missing, claims may be delayed, placed on hold or denied — often leading to avoidable resubmissions or appeals. Submitting complete documentation with a claim helps prevent delays.
 

Common documentation gaps that delay claims

Delta Dental's Clinical Review Team looks for information to help determine coverage and medical necessity. Missing or incomplete information during initial review can lead to claim denial and medical necessity appeals that could have been avoided. Addressing these gaps early can significantly reduce appeal volume.

Incomplete submissions may be missing information or may lack important detail, like:

• Clinical notes or diagnostic findings
• Treatment narratives
• Legible, diagnostic‑quality radiographs or supporting images
  • Radiographs should be clear and readable, allowing us to make a clinical determination. Images that are not of diagnostic quality (such as those with cone cuts, overlapping structures, foreshortening or elongation) or submitted in formats that limit visibility may result in denials.
• Clear linkage between diagnosis and the billed treatment
• Alignment between billed procedure codes and the supporting clinical documentation
• Required identifiers
   

Complete submissions support faster payment

When additional documentation is needed, claim review may pause while records are requested, extending dispute resolution and delaying payment.

Submitting complete and accurate documentation with the initial claim helps:

• Reduce requests for additional information
• Avoid unnecessary delays
• Support faster claim decisions and payment
   

Tip: Consult the Dentist Handbook (accessible via Provider Tools) to better understand what documentation should be submitted with the initial claim.
 

Resubmission vs. appeals

Review the Explanation of Benefits (EOB) carefully before taking next steps. In many cases, the EOB indicates a claim could not be fully processed due to missing information.

If additional documentation is requested, resubmitting the claim with the required records is often more efficient than submitting a formal appeal. Resubmissions help avoid extended appeal timelines and support quicker resolution.

Utilizing the resubmission process helps:
 

• Correct administrative or clerical issues more quickly
• Reduce unnecessary appeal processing
• Prevent delays in claim review and resolution
   

Appeals should be submitted only after the resubmission process has been fully utilized and a formal appeal is warranted.
 

Use available resources to prevent delays

Providers are encouraged to reference:
 

• Provider Tools to identify documentation requirements
• The Dentist Handbook for coverage guidelines and clinical documentation expectations
   

Approaching claim submission with these resources in mind can help reduce resubmissions, appeals and administrative burden — allowing claims to move through the process more smoothly.