x

Appeal Request Form

Delta Dental of Kansas - Appeal Request Form and Instructions

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:

  • To submit an appeal, complete the form in its entirety and attach all documents, records and any other information related to the claim.
  • List all documents you submit with your appeal in the Claim Information section of the form.
  • If submitting radiographs, photos and/or periodontal charts, make sure all documents are clearly dated. Please reference the NEA number in the Claim Information section, if applicable.
  • Include a copy of the remittance advice or pre-treatment estimate as applicable.
  • If you have any questions, please contact our Customer Service team at 1-800-234-3375.

Member Information

Dentist Information

Claim Information

Upload
Upload
Upload
Upload
* Required Field