Focused Review

This is a period of time in which a provider’s claims for a select group of procedure codes are manually reviewed to ensure appropriate documentation is being submitted and group contract guidelines are being met.

Many claims are processed without requiring supporting documentation. This allows us to process claims more efficiently and cost effectively, and reduces some of the burden on providers. To still ensure claims are paid accurately and appropriately, we use Focused Review to review a sample of claims instead of requiring supporting documentation for all claims, which saves everyone time and money.

Focused Review generally lasts at least six months, and may continue on a month-to-month basis thereafter until we are able to determine that billed services were necessary and complied within billing, documentation and benefit guidelines.

If you are placed on Focused Review, you will receive a letter and reference sheet explaining the process. It’s very important to read through the information, which will ensure a smooth process. Here are a few items to note:

1. You can continue using the Dental Office Toolkit® (DOT) or your electronic claim submission process to submit claims and attachments. This is the preferred method of claim submission to Focused Review. The ability to add attachments to your initial claims submissions is now available in DOT. Users can submit up to 10 attachments with a maximum file size of 5MB each. Accepted file types include PNG, JPEG, TIFF, GIF and PDF.
    
2. Paper claim submissions with supporting documentation should be mailed to the Focused Review department at:
   
   Delta Dental—Focused Review
   PO Box 9116
   Farmington Hills, MI 48333-9089
   
   It is essential that this address is used. If information is not sent to the correct address, data may be lost and/or payment may be delayed. Claims not under Focused Review may be submitted as usual. 
    
3. For questions about the Focused Review program or Focused Review claim determinations, please contact the Focused Review department at (888) 661-8553 or at focusedreview@mydeltadental.com. This email address is for inquiries only and claims cannot be accepted. For all claims not on Focused Review, continue to call your Customer Service department. Patient inquiries should be directed to Delta Dental’s Customer Service department. 
    
4. As long as all requested documentation is correctly submitted, claims under Focused Review will be processed according to your state's prompt payment regulations. To ensure timely payment, it is very important that instructions in the Focused Review packet are followed.
    
5. A periapical radiograph may be required along with a bitewing radiograph, which allows our dental consultants to evaluate the tooth above and below the gum line.

There are several reasons why a claim may not be paid:

• Each Delta Dental group contract is different, and a procedure that is allowed for one group may not be allowed for another. Or a group contract may have specific requirements or documentation needed for a procedure to be covered. A group contract also overrides the Delta Dental Provider Handbook. Submitting pre-treatment estimates is optional and can be infinitely valuable in ensuring your patients know what is covered under their group plan.
• The claim was not submitted with all necessary supporting information (i.e., missing radiographs, treatment record, etc.).
• Claims were sent to an incorrect mailing address or did not include the requested information.
• The services performed did not adhere to generally accepted standards of dental practice.
• There is proof and/or reasonable suspicion of fraud.

If you would like reconsideration of a claim that is denied or determined not billable, submit a new claim to Focused Review, containing:

• New pertinent information and all information initially submitted.
• If a new claim and the required information are not received, the request for reconsideration will be determined not billable.
• Only one reconsideration request per service will be accepted.

Delta Dental analyzes the percentage of claims denied/not billable to the patient, and providers are removed from Focused Review after determining that billed services were necessary and complied with billing, documentation, and benefit guidelines.