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Most — if not all — major benefits carriers employ a staff of clinical experts to review claims — so it’s not groundbreaking to say that we have dentists on staff to review claims submissions.

However, would it surprise you to learn that we have nearly 50 people on staff whose names are followed by the initials DDS or DMD? While other carriers also offer consultant claims review, we consider our dental staff an integral part of our value proposition. And because we consider this so important, dental consultant review isn’t subcontracted to an outside agency or delegated to untrained staff.

Dental consultant reviewing xray

Using radiographic imaging and detailed treatment descriptions, our dentists determine whether coverage for treatment is approved or in certain cases, denied. In other words, our dentists ensure that benefits are used and applied fairly.

Dr. Joseph Borg, our Director of Dental Policy says, “Our processing policies, backed by our staff of dental consultants, are beneficial to our clients and their employees because they ensure oversight of their benefits dollars — we’re making sure that services are administered and processed appropriately.”

Our dental consultants personally evaluate more than 200 claims per day, ensuring that:

  • Treatment and billing for pre-defined services (e.g., crowns, bridges and periodontal surgery) are appropriate and meet Delta Dental’s stated clinical guidelines.
  • Exceptions to frequencies and/or age limitations are made where appropriate or necessary.
  • Treatment is billed appropriately; for example, a complex service isn’t “unbundled” into a variety of separate codes.

Dr. Thomas Gale, a dental consultant in our Alpharetta, Georgia office notes, “We want enrollees to get the most from their benefits — the care they expect, the care they require and the care they’re charged for.”

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