What is a peer-to-peer discussion?
Treating dentists may need further explanation of the clinical rationale for an adverse (negative) clinical determination as indicated by a “denial” or “not billable to patient” on the related explanation of benefits. The negative determination may be based on:
- An adverse medical necessity determination
- An adverse clinical appropriateness determination
If further explanation is needed, a 20-minute Peer-to-Peer discussion with one of our dental consultants may be requested. Peer-to-Peer discussions are NOT available for negative determinations related to:
- Contractual exclusions
- Contractual limitations
- Benefit exhaustion
- Other contractual provisions of a patient's dental plan which do not require a medical necessity or clinical appropriateness determination.
A Peer-to-Peer discussion is NOT considered a reconsideration nor an appeal and will NOT result in a change to the original determination.
Who can request and participate in a peer-to-peer discussion?
Anyone in the provider’s office may request a Peer-to-Peer discussion by completing and submitting ALL fields in the form below. Once scheduled, only the treating dentist may discuss the relevant determination(s) with an appropriate reviewer.
When will my peer-to-peer discussion be scheduled?
Upon receipt of your request, Delta Dental will contact your office within 60 calendar days to schedule your Peer-to-Peer discussion. Please be prepared to provide at least two callback times during the business hours of 9 a.m. to 3 p.m. Eastern Standard Time.
What Delta Dental organization is providing this service?
This is a Delta Dental of Michigan delegated responsibility provided in collaboration with the following Delta Dental organizations:
- Arkansas, Indiana, Minnesota, New Mexico, North Carolina, Nebraska, Ohio, South Dakota, Wisconsin, and Virginia
Unique programs
Most negative clinical determinations are eligible for a Peer-to-Peer discussion; however, the following programs have unique limitations:
- Michigan Healthy Kids Dental and MI Health Plan providers - Please note that you must FIRST submit a provider appeal of a denied dental procedure to Delta Dental before requesting a Peer-to-Peer discussion. Refer to your Healthy Kids Dental Program and/or MI Health Plan Office Guide section on grievances and appeals for more information on the provider appeal process.
Before you submit the form below
Prior to submitting the form below and requesting your Peer-to-Peer discussion, please review the processing policies on your explanation of benefits and/or the referenced clinical criteria found here.
Should you decide that additional clinical documentation would support the medical necessity and/or appropriateness of care for the related dental services, you may submit a reconsideration before requesting a Peer-to-Peer discussion.
If you have general questions not related to clinical determinations, our Customer Service team may be able to help you, please contact them using the information found in the Contact Us section of our website.
How do you know if your form was successfully submitted?
- Success! – When the form disappears, the page returns to the Peer-to-Peer Discussion page with a final sentence stating, “Thank you for contacting us. Your form has been submitted.”
- The submission failed – When the required information is not provided, the online form will prompt you to “please enter a value.”
- All fields are required and must be completed in order for a Peer-to-Peer discussion to be made.