Member Appeals Process
The following describes the internal process used by Delta Dental to resolve disputes from members involving the application of the terms and conditions of the client contract to Delta Dental's processing of a claim. Complaints regarding a decision to deny, reduce, or terminate coverage may be addressed using these procedures.
When a member believes Delta Dental has incorrectly processed a claim, the following steps are taken, as appropriate and in accordance with client contract provisions, Delta Dental policies and any applicable law.
The member must contact Delta Dental by calling the customer service department at (800) 524-0149 or by sending written correspondence to the professional services department requesting an appeal to determine if the claim in question was correctly adjudicated. Written correspondence should be sent to:
Attn: Professional Services Department
PO Box 30416
Lansing, MI 48909-7916
If the customer service department receives the appeal, all information received will be forwarded to the professional services department.
A professional services analyst will review the claim in question, the member's claim history, all supporting information received and if necessary will obtain copies of the client/summary of benefits. If the appeal can be resolved using this information, the analyst will contact the member with the final resolution and if needed, request an adjustment to the claim in question.
If the appeal cannot be resolved using the above information, professional judgment by a professional services dental consultant may be required. The dental consultant will review all previous decisions made as well as additional information received. Once a decision has been reached by the dental consultant, the information will be returned the professional services analyst. The analyst will contact the member with the final resolution and if needed, request an adjustment to the claim in question.
If, after receiving the final resolution, the member believes Delta Dental has still incorrectly denied all or part of the claim, the member may, as appropriate, file a complaint with his/her state insurance commissioner (for disputes related to client contract issues, i.e., application of contract exclusions, limitations and/or policies), or with his/her state dental association peer review entity (for disputes related to professional judgment).
In Ohio, if a claim has been denied on the basis that it is not a covered service, the member has a right to file a complaint with the "Ohio Department of Insurance, Consumer Services Division, 50 West Town Street, Third Floor — Suite 300, Columbus, OH 43215, (614) 644-2673, toll free in Ohio (800) 686-1526." Complaints may also be filed online at http://insurance.ohio.gov.