Peer-to-peer program
As a courtesy and an opportunity for a professional exchange of information, Delta Dental of South Carolina (DDSC) offers dentists the ability to converse with a dental consultant to understand why a claim was denied. The purpose and objective of a peer-to-peer call is to review a disputed claim or predetermination decision and to obtain any additional pertinent clinical information that may not have been available at the time the initial review was conducted. This is an opportunity for the dentist to provide additional information that may not have been submitted with the claim or may not have been apparent from the image or the narrative.
Information conveyed during a peer-to-peer call for the purpose of enhancing the case for reversal of a claim or predetermination decision does not guarantee that the claim or predetermination decision will be reversed. If any additional information provided during the peer-to-peer conversation gives the dental consultant reason to consider changing the original claim decision, the entire case with the additional information is provided to a different dental consultant for review. If two out of three dental consultants agree that the claim decision should be changed, the original denial will be overturned.
The denial of a claim for services provided can sometimes create an emotional reaction on the part of the dentist whose claim has been denied. We encourage the dentist to understand that denials are based on the criteria set forth in a contract between DDSC and the employer. The criteria or processing policies are the rules that DDSC must follow on behalf of the employer. The purpose of peer-to-peer calls is to provide an avenue for the exchange of information between professionals. At DDSC, we will do our best to serve this purpose.
Peer-to-peer call requests may be submitted through your professional relations representative, customer service representative, electronically or USPS.
Second Re-Eval program for claims
A predetermination or claim is eligible for a Second Re-Eval if your office has received a remittance advice where the submitted code has been replaced with another code or it has been denied by a dental consultant. For example: Per consultant review benefits are not available.
Second Re-Eval requests may be submitted through USPS mail, electronically or through your professional relations representative. The submission of a second re-eval should include any additional information such as x-rays, photos, operative/chart notes, and periodontal charting. The previously submitted clinical documentation along with the claim/predetermination number that was previously denied or recoded should also be submitted with your new claim or predetermination.
