DentaQuest Authorization Process

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.

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 “with claim:”

 
“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 treatment






How long does it take to determine a submitted prior authorization?

 
Standard Prior Authorization Submissions Expedited Prior Authorization
Submissions
3 Business Days 1 Business Day





How long is an authorization valid?

 
Authorization Expiration Timeframe
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.
 

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