Utilization Management Information

DentaQuest reminds all providers to utilize the dental provider office reference manual prior to all rendering all dental services. All required documentation necessary for DentaQuest to make a determination and claims payment is housed here.  Lack of documentation could result in a denial for services or claims payment.
DentaQuest has developed a philosophy of Utilization Management that recognizes the fact that there exists, as in all healthcare services, a relationship between the dentist’s treatment planning, treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community practice patterns” of local dentists and their peers. With this in mind, DentaQuest’s Utilization Management Programs are designed to ensure the fair and appropriate distribution of healthcare dollars as defined by the regionally based community practice patterns of local dentists and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns. DentaQuest’s Utilization Management Programs recognize that there exists a normal individual dentist variance within these patterns among a community of dentists and accounts for such variance. Also, specialty dentists are evaluated as a separate group, and not with general dentists, since the types and nature of treatment may differ.  DentaQuest’s Utilization Management Programs evaluate claims submissions in such areas as:

  • Diagnostic and preventive treatment;
  • Patient treatment planning and sequencing;
  • Types of treatment;
  • Treatment outcomes; and
  • Treatment cost effectiveness.
Participating Providers that disagree with determinations made by the DentaQuest dental directors may submit a written Notice of Appeal to DentaQuest that specifies the nature and rationale of the disagreement. This notice and additional support information must be sent to DentaQuest within 60 days from the date of the original determination to be reconsidered by DentaQuest’s Peer Review Committee.

DentaQuest of New Mexico, LLC
Attention: Utilization Management/Provider Appeals
11100 W. Liberty Drive
Milwaukee, WI 53224

All notices received shall be submitted to DentaQuest’s Peer Review Committee for review and reconsideration. The Committee will respond in writing with its decision to the Provider.