The review of dental claims to determine whether or not the codes submitted for the service provided is supported by the two-dimensional image and the narrative is a very challenging effort. At Delta Dental of South Carolina (DDSC) our dental consultants recognize these limitations. They utilize all their clinical experience and background when reviewing claims. However, these are the limitations that we must work with.
As a courtesy and an opportunity for a professional exchange of information, 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 create a very emotional reaction on the part of the dentist whose claim has been denied. I would like 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 for 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.
