Providers:
Check out our monthly must-read designed to help you stay informed, save time and focus on patient care.
Reminder: Urgent prior authorization requests
To ensure timely and appropriate review of prior authorization and other review requests, requests submitted as urgent or expedited must meet the CMS definition of an expedited request and be supported by clinical documentation demonstrating the urgent need.
CMS defines an expedited/urgent request as:
“A request for a determination in which waiting for a decision under the standard timeframe could place the member's life, health, or ability to regain maximum function in serious jeopardy.”
Providers are encouraged to carefully assess the clinical circumstances and submit all relevant supporting documentation at the initial submission to avoid delays in processing.
Reminder: Dental home assignments
We’re proud to be the sole carrier for Healthy Kids Dental (HKD) members starting Oct. 1, 2026. To provide access to all members, current and new HKD members will be assigned to a primary dental provider—called a “dental home.” The dental home model helps members know where to get care by connecting them with a high-quality dentist who provides ongoing, preventive care and coordinates specialist referrals when needed.
Note:
- Members retain flexibility to visit any participating dentist. They are not restricted to their dental home and are able to choose a different provider if they wish.
- Members not assigned to your office may also still be seen and will be reimbursed as usual.
For questions, please contact your professional services representative.
New adult Medicaid network going live Jan. 1, 2027
Our new Healthy Adult Dental (HAD) network will go live Jan. 1, 2027.
HAD will replace our Michigan TriState Advantage network, becoming the sole network for adult Medicaid, Healthy Michigan Plan and MI Coordinated Health (MICH) members. This change is to strategically support anticipated membership growth and improve overall network efficiency.
Please watch your Inbox for a provider contract Amendment via a DocuSign link for convenient completion. Please complete this by Nov. 6 to avoid claim delays. Alternatively, the Amendment can be downloaded online and emailed to gpproviderrequests@mydeltadental.com or faxed to 517-381-5649.
Cracking the code: D4249 (crown lengthening) vs. D4212 (gingivectomy for restorative purposes)
D4212
D4212 is appropriate when only soft tissue is removed to gain access for a restoration.
D4249
D4249 should be reported only when the procedure includes flap reflection, osseous resection and exposure of additional tooth structure through hard-tissue removal. Documentation for D4249 should clearly support bone removal and the restorative need for crown lengthening.
Quick tip:
If no bone is removed, D4212 is generally the appropriate code. If bone removal is required to expose additional tooth structure for restoration, consider D4249.
Medicare Advantage requirement: Type 2 National Provider Identifier
Providers submitting claims for Medicare Advantage members must have a Type 2 National Provider Identifier (NPI) on file for their business. Federal law requires all healthcare providers and organizations use a standard identifier in their administrative and financial transactions.
All electronic claims submitted to Delta Dental must include:
- Treating dentist’s Type 1 NPI
- Treating dentist’s state license number
- Tax Identification Number (TIN) of the billing dentist or practice
- Type 2 NPI to identify the billing provider, following these guidelines:
- Multiple dentists at one practice location (group practice, partnership): Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN.
- Multiple dentists at multiple practices (clinics, dental service organizations, etc.): Type 1 for each dentist and Type 2 for each practice, with a separate TIN.
Dental Office Toolkit™ (DOT) enhancements
Several enhancements have been made to improve the claims experience in DOT, including expanded claim views for members and families, improved search and filtering options, claim export to CSV and enhanced treatment detail visibility through expandable claim information.
Additional updates, such as sortable columns and streamlined action buttons, make it easier to find, review and manage claims.
First accredited dental therapy program
In 2028, Ferris State University will offer an accredited dental therapy program—the first of its kind in Michigan. Although Michigan currently has two practicing dental therapists, both had to pursue their education out of state, with funding from the Delta Dental Foundation, Michigan Health Endowment Fund and the Michigan Primary Care Association.
Ferris State’s first dental therapy class will accept 12 students, and the program will be open to students from a variety of educational backgrounds. Read more about Ferris State University’s dental therapy program: “Ferris taps public health dentist to launch Michigan’s first dental therapy program.”