Prior Authorization
Use the steps on this page when prior authorization is required.
For procedures where “Authorization Required” fields indicate “yes”. Please review the information below on when to submit documentation to DentaQuest. The information refers to the "Documentation Required” field in the Benefits Covered section (Exhibits). In this section, documentation may be requested to be sent prior to beginning treatment or “with claim” after completion of treatment.
Authorization Process
When documentation is requested:
| "Review Required" Field | "Documentation Required" Field | Treatment Condition | When to Submit Documentation |
| Yes | Details on what specific documentation is required | Non-emergency (routine) | Send documentation prior to treatment |
| Yes | Details on what specific documentation is required | Emergency | Send documentation with claim after treatment |
When documentation is requested:
| "Review Required" Field | "Documentation Required" Field | Treatment Condition | When to Submit Documentation |
| Yes | Documentation Requested with Claim | Non-emergency (routine) or emergency | Send documentation with claim after |
How long does it take to determine a submitted prior authorization?
- Standard Prior Authorization Submissions: 3 Business Days
- Expedited Prior Authorization Submissions: 1 Business Day
How long is an authorization valid?
- 180 days from the determined date
What documentation will the member and provider receive after an authorization is determined?
Prior authorization requests are determined within three business days for standard requests and one business day for expedited requests. Once DentaQuest has reached a decision for the prior authorization request, a written notice of the decision is sent to the member, with a carbon copy sent to the provider within 24 hours of the determination. The written notice, or letter, will include the services requested, the decision made, either denied or approved. For denied services, the letter will also include the reason for the decision and the criteria applied. The letter for denied services will include more information for the member to tell them how they can request a copy of the criteria applied and information about the appeal rights and instructions how to request an appeal.
Notification process for incomplete prior authorization requests:
When essential information is missing from a prior authorization, DentaQuest will notify provider and member no later than three business days after the PA was received, with explanation of what is missing/incorrect/illegible. When possible, a call will be made to the provider to obtain missing information.
If the documentation is not received by DentaQuest by the end of the third business day after prior authorization receipt date, a Dental Consultant will review the prior authorization with the information received in the initial request.
Within three business days after the prior authorization has been sent for Dental Consultant review, but no later than the tenth business day after the receipt date, a final notice will be sent to the provider and member of the Dental Consultant’s decision.
Final decisions will be made within three business days after the missing information was received by DentaQuest.
Holidays may result in the process exceeding the fourteen day time limit and DentaQuest will adjust accordingly.
Have questions or need assistance?
If you're a provider and have questions or need assistance with a submitted authorization, please contact Provider Services at 800-896-2374 or your local Provider Partner.
If you're a member and have questions or need assistance with a submitted authorization, please call one of the below Member Hotlines:
- Medicaid Members: 800-516-0165
- CHIP Members: 800-508-6775
- For Hearing Impaired: 7-1-1
- Mon-Fri: 8 a.m. to 6 p.m. Central Time
Important Documents:
PREVENTISTRY PULSE
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