We’re pleased to welcome Dr. Basma Armanious, DMD, MA, to Delta Dental of Virginia. In her role, Dr. Armanious brings a clinical perspective to help support our dental partners and provide helpful guidance on claims, coding and other topics that affect your practice.

In this issue of Dentist News, Dr. Armanious shares five practical tips to help make the claim appeal process clearer and easier to navigate.

5 Tips for a Smoother Claim Appeal

At Delta Dental of Virginia, our goal is to make the claim appeal process clear, helpful, and easy to navigate. Below are a few tips that your practice can follow to make the appeal process move quickly and smoothly.

1. Complete documentation can support a timely review

When additional information may support a denied or adjusted claim, an appeal gives the claim another careful review. The most helpful appeals tell clearly: what was done, why it was needed and how the documentation supports the submitted CDT code.

Appeals are member appeals. With written authorization, a provider may submit an appeal on the member’s behalf. Delta Dental of Virginia plans traditionally allow two levels of member appeals for adverse claim determinations, each with its own timeline.

2. What helps us take a fresh look

A strong appeal connects the clinical findings, treatment and the code submitted. Please label the submission as an appeal, include the original claim number and briefly explain what should be reconsidered. Also be sure to include:

• Clinical photographs or diagnostic images, when appropriate
• Detailed clinical notes and a clear narrative
• Patient-specific details that support the service
• Documentation showing how the service supports the CDT code submitted

3. New information matters

New or clarifying information can make a real difference. If the same, or incomplete information is resubmitted without added context, the outcome may not change.

4. What an appeal can and can’t change

Some decisions are based on the member’s dental benefit plan; others are based on whether documentation supports the code or service submitted. Annual maximums, frequency limits, waiting periods and non-covered services generally cannot be changed through appeal. However, coding or clinical review determinations may be reconsidered when new or clearer documentation supports the CDT code.

5. A note on timing

First-level appeals must be received within 180 days of the adverse determination. If upheld, a second-level appeal may be submitted within 60 days of the first-level appeal determination.

Always submit appeals in writing in one of two ways: 

1. by email to AppealsAdmin@DeltaDentalVA.com, or 
2. by mail to: Appeals Department

Delta Dental of Virginia

PO Box 12483, Roanoke, VA 24026

If you need more information, the Delta Dental of Virginia Dentist Handbook

is a helpful resource for appeals, claims processing, documentation requirements, coding guidance and reimbursement information. The Handbook can be found in the Documents after logging in at DeltaDentalVA.com/dentists.

Thank you for your partnership with the appeal process. As always, we are here to help. Call Benefit Services at 800.237.6060 with any questions.