Privacy notice

Dental Provider Correspondence Request

This form is used to submit your narrative and supporting documentation such as explanation of payment (EOP), clinical records, chart notes, and x-rays. Submission of this request without documentation will result in processing delays. Attach all files using the ATTACH FILES feature at bottom of form. All services are subject to eligibility and plan provisions in effect at the time services are rendered.

Example of items that can be submitted through the webform.

• Requests for reconsideration of denied claims for Delta Dental when extenuating conditions exist.

Example of items not accepted through the webform.

• Any program questions or issues for the Oral Health, Total Health program or the Intellectual and/or Developmental Disabilities program. For these inquiries, please contact Dental Customer Service at 888-217-2365
• Responses to a request for additional clinical information
• Responses to letters requesting missing information
• Corrections to previously submitted claims or submission of new claims
• Predeterminations for any services
• Member appeals

If these types of items are submitted using the webform, they will be rejected, and you will need to resubmit the request following the current process.