What is Focused Review?
This is a period of time in which a provider’s claims for a select group of procedure codes are manually reviewed to ensure appropriate documentation is being submitted and group contract guidelines are being met. Most often, Focused Review occurs randomly. It may also occur due to statistical differences in claims compared to peers, or customer complaints. A very small number of providers are under Focused Review at any given time.
Why does Delta Dental do Focused Review?
Over the past few years, we have eliminated several mandatory radiograph requirements for certain codes. This allowed us to process claims more efficiently and cost effectively, and reduced some of the burden on providers. To still ensure claims are paid accurately and appropriately, we switched to this new system of random review instead of always requiring the documentation, which saves everyone time and money.
How long does Focused Review last?
Typically, Focused Review lasts 6 months. If additional information is needed after 6 months, the Focused Review status may continue on a month-to-month basis.
What are the special requirements of Focused Review?
If you are placed on Focused Review, you will receive a letter and Reference Sheet explaining the process. It’s very important to read through the information, which will ensure a smooth process. Here are a few items to note:
(1) All requested Focused Review claims should be submitted directly to the Focused Review Department at:
Delta Dental—Focused Review
PO Box 9116
Farmington Hills, MI 48333-9089
If information is not sent to the correct address, data may be lost and/or payment may be delayed. Claims not under Focused Review may be submitted as usual.
(2) All inquiries about Focused Review and claims under Focused Review should be directed to the Focused Review Department at 888-661-8553.
(3) As long as all requested documentation is correctly submitted, claims under Focused Review will be processed according to your state's Prompt-Pay regulations. To ensure timely payment, it is very important that instructions in the Focused Review packet are followed.
(4) Claims submitted electronically through NEA, RSS, and Dental Office Toolkit (DOT) should include the service number in the ‘Remarks’ section. Also, let the Focused Review Department know you will be submitting claims electronically.
(5) A periapical may be required along with a bitewing radiograph, which allows our dental consultants to evaluate the tooth above and below the gum line.
Why were some claims paid prior to Focused Review, but now they are being denied/disallowed?
There are several reasons why a claim may not be paid:
Each Delta Dental group contract is different, and a procedure that is allowed for one group may not be allowed for another. Or, a group contract may have specific requirements or documentation needed for a procedure to be covered. A group contract also overrides the Delta Dental Provider Handbook. Pre-treatment estimates can be infinitely valuable in ensuring your patients know what is covered under their group plan.
Claims were sent to an incorrect mailing address or did not include the requested information.
The services performed did not adhere to generally accepted standards of dental practice.
There is proof and/or reasonable suspicion of fraud.
How do I get removed from Focused Review?
Delta Dental analyzes the percentage of claims denied/disallowed, and providers are removed from Focused Review after determining that billed services were necessary and complied with billing, documentation, and benefit guidelines.