Peer-to-Peer Discussion

For claims other than Medicare Advantage and D-SNP preservice determinations, prior to a peer-to-peer call, please review the processing policies on your explanation of benefits and the referenced clinical criteria found under “Tools and Resources” on this web page. If you feel that additional clinical documentation would support the medical necessity, client criteria, and/or appropriateness of care for the related dental services, you may submit a reconsideration before requesting a peer-to-peer call.

The opportunity for providers to discuss denial decisions based on issues of medical necessity or appropriateness of care 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
• Renaissance Life and Health of America for providers participating in the TennCare Medicaid program

Treating dentists who need an explanation of the clinical rationale for a negative determination of a dental procedure based on an adverse medical necessity, client clinical provision, or clinical appropriateness determination, may request up to a half-hour peer-to-peer discussion with one of our dental consultants. Peer-to-peer discussions are not available for claim denials based on an exclusion, limitation, benefit exhaustion or other contractual provisions of a patient's dental plan which does not require a medical necessity, clinical review, or clinical appropriateness determination. A practitioner may receive one peer-to-peer discussion per episode of treatment unless the practitioner has new, pertinent information that is applicable to a second conversation.

To request a peer-to-peer discussion, please complete all fields in the form below. Upon receipt of your request, we'll reach out to you within 30 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. A peer-to-peer discussion may be requested on behalf of a treating dentist by dental office staff; however, the treating dentist must sign the request form and the actual peer-to- peer discussion must be conducted with the treating dentist. Dentists not involved in the provision of the related dental services may not request or conduct the peer-to-peer call. 

A peer-to-peer discussion is not considered a reconsideration or appeal and will not result in a change to the original determination.

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.

How to know if your form was successfully submitted?

• Success! – When the form disappears and 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.”