Focused Review 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 patient complaints. A very small number of providers are under Focused Review at any given time.
Delta Dental plans of Indiana, Kentucky, Michigan, Nebraska, New Mexico, North Carolina, Ohio, and Tennessee all participate in this random review process. The Delta plans of these states do not have as many documentation requirements as some of the other Delta plans in other states, which is why Delta utilizes the focused review process to ensure that claims are being paid appropriately and contractual guidelines are being met.
Providers selected to participate in Focused Review are typically in review for six months and will receive a notification packet from Delta explaining which procedures will be in review along with a checklist of the documentation required for the procedures that will be reviewed. 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.
If you have been selected for Focused review, all inquiries should be directed to the Focused Review Department at (888) 661-8553.