FYI

Delta Dental is committed to conducting fair, thorough and objective reviews of grievances, appeals, quality of care concerns and provider disputes. To make accurate determinations, we rely on complete and timely information from all parties involved, including our provider partners.
 

Why we may request information

Requests for records and supporting documentation may be associated with:

• Member grievances or complaints
• Member appeals
• Quality of care investigations
• Regulatory reviews
• Provider appeals and disputes
• Clinical reviews or second opinions
   

Submit complete documentation with provider appeals

To help streamline the review process, we encourage providers to include all applicable supporting documentation when submitting an appeal. Depending on the case, this may include chart notes, radiographs, photographs, treatment plans, referral documentation, clinical narratives and other relevant records. Complete submissions can help reduce follow-up requests, minimize delays and support faster determinations.
 

Response timeframes

When Delta Dental requests documentation, providers are required to submit complete, accurate and legible records at no cost to Delta Dental or the member. All requested records should be submitted using the contact information provided in the Request for Information (RFI) letter to ensure timely review and processing.
 

• Standard requests. Documentation must be submitted within 7 calendar days of the request, unless otherwise required by applicable regulations or plan requirements.
• Expedited requests. Urgent cases may require a response within 24 hours to 3 calendar days, depending on the circumstances and regulatory requirements.

Why timely responses matter

Timely responses help ensure reviewers have the information needed to fully evaluate a grievance, appeal, dispute or quality of care concern. If the requested records are not received, Delta Dental may be required to proceed with its review using the information available at the time a determination is made.

In some cases, failure to provide requested information may result in administrative action, payment withholds, adverse determination outcomes or other actions consistent with applicable provider agreements and program requirements.

Prompt responses help Delta Dental:

• Conduct balanced and comprehensive reviews
• Meet regulatory requirements
• Resolve cases more efficiently
• Support quality improvement and patient safety efforts
• Ensure fair consideration of both member and provider perspectives
   

Without complete provider information, we may be unable to fully evaluate the circumstances surrounding a treatment, service, complaint or appeal.

Delta Dental values the partnership of our provider community. Whether responding to a request for information related to a grievance, appeal, quality of care review or provider dispute, timely and complete documentation helps ensure every case is reviewed fairly, objectively and based on the most complete information available.

By providing relevant records as early as possible, providers can help reduce delays, minimize the need for additional follow-up, and support an efficient review process that protects the rights of both members and providers while promoting high-quality care across our network.
 

Tips for maintaining complete patient records and avoiding delays

One of the most effective ways to support timely grievance, appeal, dispute, and quality of care reviews is to maintain complete, accurate patient records at the time services are rendered. The Dentist Handbook outlines provider requirements for maintaining comprehensive records that clearly document the care provided and support clinical decision-making. Complete documentation not only supports continuity of care, but also helps facilitate efficient reviews when records are requested.

To help avoid delays and minimize additional requests for information, consider the following best practices:
 

• Document services contemporaneously. Complete chart notes at the time of treatment and clearly document the patient's condition, diagnosis, treatment provided and clinical rationale.
• Maintain supporting clinical documentation. Retain radiographs, photographs, periodontal charting, treatment plans, referral documentation and other records that support treatment decisions.
• Keep required consent forms on file. Ensure informed consent forms and other required patient authorizations are signed, dated and maintained in the patient's record.
• Ensure records are complete, organized and legible. Documentation should be readily accessible for review when requested. Incomplete, illegible or missing records may delay the review process and determination outcomes.
• Retain relevant correspondence. Maintain records of referrals, specialist consultations, member communications and other treatment-related documentation that may be needed during a review.
• Submit complete appeal packages. When filing a provider appeal, include all relevant supporting documentation, such as clinical records, narratives, radiographs, photographs and treatment plans. Providing complete information upfront can reduce follow-up requests and help expedite the review process.

A proactive approach to recordkeeping can help streamline reviews, reduce administrative burden and ensure determinations are based on the most complete information available.