Providers or members who wish to file a formal appeal related to an adverse benefit determination must complete the Delta Dental of Kansas Appeal Request Form. This form should only be used to submit an appeal.
The Appeal Request Form must be received by Delta Dental of Kansas within 180 calendar days from the date of the original adverse benefit determination or the corresponding remittance advice.
After receiving this Appeal Request, Delta Dental of Kansas will either send you a written decision regarding your appeal or, if necessary, request additional information regarding your appeal within 20 business days of receipt. However, when special circumstances arise, Delta Dental of Kansas may require additional time to reach a final decision.
Appeals Request Form Checklist: