Delta Complaint Form

Delta Dental Complaint Form for Dentists

What problem are you having with Delta Dental? (See below for examples of each)

Non-Covered Services/ Dictating Payment outside of Contract
Prescribing Treatment
Dictating Standard of Care
Other

Non-Covered Services/ Dictating Payment outside of Contract: The dental benefits company is mandating the contracted fee schedule on a service for which the patient does not have a benefit.

Prescribing Treatment: The dental benefit company is deciding what treatment the patient receives through denying covered benefits or restricting treatment to specific services. For example, the patient and the doctor have agreed that a particular treatment plan is the best course of action, but the benefits company disallows a specific service in favor of lesser service. Or the benefit company consistently denies a particular service forcing multiple appeals and reviews.

Dictating Standard of Care: The dental benefit company is setting the standard of care by dictating when certain procedures will be performed AND it does not conform to current best practices / standard of care. For example, not covering a crown unless there is displacement of enamel.

Please outline the specifics of your complaint:

Do not include any patient identifiable information as this site is not intended to be HIPAA compliant.

Name

Phone Number

Email Address