Medicaid Complaints and Appeals

Complaint Process

What should I do if I have a complaint?
We want to help. If you have a complaint, please call us at 1-800-516-0165 (toll-free) to tell us about your problem or write to us at:
 
DentaQuest TX Dental Services
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
1-800-516-0165
ATTN: Complaints & Grievances

 
You may use this form if you would like to write to us:
 
TX Medicaid Complaint Form
 
DentaQuest Member Services Advocate can help you file a complaint. Most of the time, we can help you right away or within a few days.

If you still have a complaint after you’ve gone through the DentaQuest complaint process, call the Texas Health and Human Services Commission (HHSC) at 1-800-252-8263 (toll-free). If you want to make your complaint in writing, please send it to the following address:
 
Texas Health and Human Services Commission
Health Plan Operations - H-320
P.O. Box 85200
Austin, TX 78708-5200
ATTN: Resolution Services

 
Who do I call?
Please call us at 1-800-516-0165 (toll-free) to tell us about your problem. A DentaQuest Member Services Advocate can help you file a complaint.

Can someone from DentaQuest help me file a complaint?
Yes, please call our Member Services line at 1-800-516-0165 (toll-free) and a Member Advocate will help you file a complaint.

What do I need to do to file a complaint and how long will the process take?
We will process your complaint within 30 calendar days from the day we receive it. Here is what will happen:
  • • You send us a written complaint.
  • • We will send you a letter within five (5) business days. Our letter will say that we have received your written complaint.
  • • We will review the details of your complaint.
  • • We will send you an answer within thirty (30) calendar days.
Our response to your complaint will be in a letter. That letter will give:
  • • Our decision about your complaint.
  • • The reasons for our decision.
  • • The specialty area of any dentist we asked to help us with your complaint.
  • • Information about filing an appeal.
If I don’t like what happens with my complaint, who else can I call?
You can call the Texas health and Human Services Commission (HHSC) at 1-800-252-8263 (toll-free).

How can I file a complaint with HHSC after I have gone through the DentaQuest complaint process?
If you want to make your complaint in writing, please send it to HHSC at the following address:
 
Texas Health and Human Services Commission
Health Plan Operations - H-320
P.O. Box 85200
Austin, TX 78708-5200
ATTN: Resolution Services

You can also call HHSC at 1-800-252-8263 (toll free).

 

Appeal Process

What is an appeal?
An appeal is the formal process by which a Member or his or her representative requests a review of DentaQuest’s actions.
 
What can I do if DentaQuest denies or limits a service for my child that the dentist has asked for?
If you do not agree with DentaQuest’s decision to your original com­plaint, you can ask for an appeal.

How will I find out if services for my child are denied?
We will send you and your dentist a letter.

What are the timeframes for the appeal process?
You must ask for an appeal within 30 calendar days after DentaQuest sends you a decision or action about your original complaint. To make sure your child continues to get his/her current dental services, you must file your appeal within 10 calendar days after you get DentaQuest’s decision to your complaint. This ensures that DentaQuest gets your appeal before the effective date of their decision or action to your original complaint.

When can I ask for an appeal?
You have the right to ask for an appeal if you disagree with the DentaQuest’s decision or action. You can also ask for an appeal for partial or complete denial of payment for services.

You must ask for an appeal within 30 calendar days after DentaQuest sends you a decision or action. To make sure your child continues to get his/her current dental services, you must file your appeal on or before the later of: 10 calendar days following DentaQuest’s mailing of the notice of action or the intended effective date of the proposed action. Either you or DentaQuest can request one, 14 calendar day extension. If DentaQuest requests an extension, it will do so in writing and must show the need for more information and how the delay is in your interest.

How do I ask for an appeal?
You can call DentaQuest to ask for an appeal. The toll-free number is 1-800-516-0165. Within five (5) business days after you call, we will send you an appeal form. You can also mail DentaQuest your appeal to:

DentaQuest TX Dental Services
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
1-800-516-0165
ATTN: Appeals Department
 
You may use this form if you would like to write to us:
 
TX Medicaid Appeal Form
 
Our address to mail your appeal to is:
 
DentaQuest-TX
Attn: Appeal Department
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
 
Or call us toll-free at: 1-800-516-0165
 
Can I just ask for an appeal or does it have to be in writing?
Every time someone asks for an appeal, that request must be written and signed by the person getting the Medicaid coverage or his or her representative, unless the person asks for an Expedited Appeal, which can be spoken or written.
Can my dentist ask for an appeal?

You, your child’s dentist, or someone that represents you can ask for an appeal. However, you will need to give your consent in writing to have another person request your appeal.

Can someone from DentaQuest help me file an appeal?
Yes. Please call our member call center for help. The toll-free number is 1-800-516-0165. Tell us that you want to file an appeal. After you have filed your appeal, DentaQuest will mail you an appeal form to complete.

What do I do when I get the appeal form from DentaQuest?
You, your child’s dentist, or someone that represents you can fill out the form and mail it back to us. Again, you will need to give your consent in writing to have another person request your appeal.
If your appeal request is for a dental emergency, we do not need a completed, signed form to process the appeal.

How soon will I hear back from DentaQuest after I mail my appeal form?
We will respond to your appeal within 30 calendar days from the day we receive your appeal form. You or DentaQuest can ask for an extension of up to 14 calendar days if there is a need for more information to make a decision. DentaQuest will send you a written notice to tell you the reason for the delay.

What else can I do if I’m still not happy?
If you disagree with DentaQuest’s decision, you have the right to ask for a fair hearing. A State Fair Hearing may be requested at any time during or after DentaQuest’s appeal process.

 

Expedited Dental Plan Appeal

What is an Expedited Appeal?
Ask for an Expedited Appeal when you don’t have time for a standard appeal - when your child’s life or health is in danger. When you ask for an expedited appeal, DentaQuest has to make a decision quickly based on the condition of your child’s health. This decision must be made within three (3) business days after we get your expedited appeal.

How do I ask for an Expedited Appeal?
You can call us to file an expedited appeal. If you need help to file an ex­pedited appeal, call our member call center for help. The toll-free number is 1-800-516-0165. Call us and tell us that you want to file an expedited appeal. We do not need your appeal in writing for an expedited appeal.

How long does an expedited appeal take?
We will make a decision within three (3) business days after we get your expedited appeal. We will call you with the decision. We will also send you a letter within two (2) business days of the decision.

What happens if DentaQuest says it won’t do an expedited appeal?
If DentaQuest does not think your appeal is life-threatening, we will let you know the same day that the decision is made. DentaQuest will make this decision within three (3) business days. Your appeal will still be worked on, but the decision may take up to 30 days.

Who can help me file an Expedited Appeal?
If you need help asking for an expedited appeal, call us toll free at 1-800-516-0165 and a Member Advocate will help you.

 

State Fair Hearing

Can I ask for a State Fair Hearing?
If you, as a caretaker of the member of the dental plan, disagree with the dental plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to DentaQuest telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by DentaQuest, you or your representative must ask for the fair hearing within 60 days of the date on DentaQuest’s letter with the decision. If you do not ask for the fair hearing within 60 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should send a letter to DentaQuest at:
 
DentaQuest TX Dental Services
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
ATTN: Fair Hearing
Or call toll free at 1-800-516-0165

If you ask for a fair hearing within 10 days from the time you get the hearing notice from DentaQuest, your child has the right to keep getting any service DentaQuest denied or reduced at least until the final hearing decision is made. If you do not request a fair hearing within 10 days from getting the hearing notice, the service DentaQuest denied will be stopped.

If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service DentaQuest denied.

HHSC will give you a final decision within 60 days from the date you asked for the hearing.


 
 

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