DentaQuest Benefit Solutions

Fill out the below information and click 'submit' to redeem your DentaQuest value added service reward.

Member Information

First Name:

Last Name:

Date of Birth:

Mailing Address:

City:

State:

Zip Code:

Phone:

( ) -

Medicaid Member ID Number:

Date You Received Care:

Your Plan:

TX Medicaid

What service did you receive at your dental appointment?

Annual Preventive Care Reward:

Age 6 months - 35 months: I had a dental check up today
Age 36 months - 5 years: I had a topical fluoride treatment today
Age 6 - 9 years: I got my 1st molars sealed today
Age 10 - 14 years: I got my 2nd molars sealed today
Age 15 - 20 years: I had my second cleaning today

Dental Visit Within 90 Days Reward:

Age 0 - 20 years: I had a dental checkup within 90 days of enrollment in Medicaid

Emergency Room Follow-Up Care Reward:

Age 0 - 20 years: I followed up with my Main Dentist and took the quiz within 30 days of a dental-related emergency room visit

Your Child's Oral Health and the ER Quiz
Take this quiz and test your knowledge.

1. Your child has a toothache. What should you do?:

A. Call your child’s Main Dentist and schedule a visit as soon as possible.
B. Wait and see if the toothache goes away on its own.
C. Take your child to a hospital ER to be seen.

2. You took your child to a hospital ER for a toothache. What should you do next?:

A. Wait and see if the problem goes away.
B. Call your child’s Main Dentist and set up a follow-up visit.
C. Plan on taking your child back to the hospital ER for additional care.

3. Your child has a toothache, but you don’t have a Main Dentist. What should you do?:

A. Go to DentaQuest.com and log into the secure member Website to find a dentist online.
B. Call DentaQuest member call center at 1-800-516-0165 and ask for help finding a dentist.
C. A or B.

4. When should you call your dentist for an immediate visit?:

A. Your child has a broken tooth or a tooth that has been knocked out.
B. Your child has pain from a cavity or lost filling.
C. Both A and B.

5. When should you take your child to a hospital ER for oral care?:

A. Your child has a serious mouth injury or infection making it difficult to breathe or swallow.
B. Your child may have a fractured or dislocated jaw.
C. Both A and B.

Medicaid Value-Added Services Redemption Form