Dental Plan Issue Form for ISDA Dentists

  • Non-covered services / dictating payment outside of contract: The benefit company applies the contracted fee schedule to procedures not covered by the patient’s dental plan.
  • Prescribing Treatment: The benefit company influences the treatment plan by denying coverage or limiting procedures, resulting in deviation from the dentist’s recommended plan.
  • Dictating Standard of Care: The benefit company applies coverage rules that conflict with recognized standards of dental practice (for example, requiring tooth structure loss before covering a crown).

Complaint Specifics

Information submitted through this form will be used only for tracking and analysis of issues reported by Idaho dentists. Please avoid including protected health information.
Contact Information
The dentist's name is required for membership verification purposes and follow-up from the appropriate committee(s). This information will not be shared outside of the organization without written permission.