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:

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