Submitting an Appeal
Delta Dental will notify you on your Explanation of Benefits (EOB) if any claims for dental services are denied stating the specific reason(s) for the denial. If you believe there is an error in processing your claim, or if you think you were overcharged by your dentist, please fill out an online inquiry. If there was an error, in most cases Delta Dental can reprocess the denial of your claim based on provided information. If you still have concerns regarding the denial of a claim for your dental services, you (or your authorized representative, if applicable) may request a review of the denial by filing a first-level appeal.
You may submit an appeal if you are:
- The TRDP enrollee (including minors; however, a parent or guardian of a minor enrollee may represent the enrollee in an appeal).
- A representative of the TRDP enrollee, appointed by a court of competent jurisdiction to act on his or her behalf.
- An individual who has been appointed, in writing, by the TRDP enrollee to act as the enrollee’s representative
First-Level Appeal Reconsideration
To be considered as an appeal:
- The appealing party must file the request within 90 calendar days after the date of the notice of the initial denial termination (for example, within 90 calendar days of the date of an EOB informing the beneficiary of a denied or reduced claim).
- The request must be in writing and may be either mailed or faxed. (Due to requirements to verify the appealing party, electronically mailed appeals are not accepted.) The appeal should state the issue in dispute, and should include a copy of all supporting documentation (e.g., a copy of the EOB) necessary for the review.
- There must be a disputed question of fact which, if resolved in favor of the appealing party, would result in the authorization of TRICARE benefits.
- The issue must be appealable.
Send your request to:
- Delta Dental of California
- Federal Government Programs Appeals Department
- PO Box 537015
- Sacramento, CA 95853-7015
Second-Level Appeal: Formal Review
You may request a formal review by the Defense Health Agency (DHA) if Delta Dental’s reconsideration decision was unfavorable, the amount in dispute is equal to or greater than $50 and the appeal is filed within 60 calendar days from the date of Delta Dental’s first-level appeal response. No amount in dispute is required when the denial addresses predeterminations (denial for dental necessity). A request for formal review should be sent to:
- DEFENSE HEALTH AGENCY
- Appeals, Hearings and Claims Collection Division
- 16401 E. Centretech Parkway
- Aurora, Colorado 80011-9066
The following issues are not appealable:
- Regulatory provisions. Based on DHA regulations, a dispute involving a regulatory provision or contractually defined issue of the TRDP (such as which procedures are covered) are not processed as an appeal.
- Allowable charge. The amount of allowable cost or charge is not appealable because the methodology for determining the charge is established by the TRDP contract.
- Eligibility for the TRDP. A person’s TRDP eligibility is not appealable because this determination is specified in law and regulation.
- Denial of services by a dentist. The refusal of a dentist to provide services or to refer a beneficiary to a specialist is not an appealable issue. This type of correspondence is categorized as a grievance and is handled accordingly.