Medicaid Complaints and Appeals

What should I do if I have a complaint?

We want to help. If you have a complaint, please call us at 1-800-516-0165 (toll-free) to tell us about your problem or write to us at:

DentaQuest TX Dental Services
P.O. Box 2906
Milwaukee, WI 53201-2906
ATTN: Complaints & Grievances

You may use this form if you would like to write to us:

TX Medicaid Complaint Form

DentaQuest Member Services Advocate can help you file a complaint. Most of the time, we can help you right away or within a few days.

If you still have a complaint after you’ve gone through the DentaQuest complaint process, call the Texas Health and Human Services Commission (HHSC) at 1-866-566-8989 (toll-free). If you want to make your complaint in writing, please send it to the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247
ATTN: Resolution Services

Who do I call?

Please call us at 1-800-516-0165 (toll-free) to tell us about your problem. A DentaQuest Member Services Advocate can help you file a complaint.

Can someone from DentaQuest help me file a complaint?

Yes, please call our Member Services line at 1-800-516-0165 (toll-free) and a Member Advocate will help you file a complaint.

What do I need to do to file a complaint and how long will the process take?

We will process your complaint within 30 calendar days from the day we receive it. Here is what will happen:

• You send us a written complaint.
• We will send you a letter within five (5) business days. Our letter will say that we have received your written complaint.
• We will review the details of your complaint.
• We will send you an answer within thirty (30) calendar days.

Our response to your complaint will be in a letter. That letter will give:

• Our decision about your complaint.
• The reasons for our decision.
• The specialty area of any dentist we asked to help us with your complaint.
• Information about filing an appeal.
   

You can also call our Member Call Center and we can tell you the status of your complaint. Call us at 1-800-516-0165.

If I don't like what happens with my complaint, who else can I call?

You can call the Texas Health and Human Services Commission (HHSC) at 1-866-566-8989 (toll-free).

How can I file a complaint with HHSC after I have gone through the DentaQuest complaint process?

If you want to make your complaint in writing, please send it to HHSC at the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247
ATTN: Resolution Services

If you can get on the Internet, you can submit your complaint at:

hhs.texas.gov/managed-care-help

You can also call HHSC at 1-866-566-8989 (toll free).

What is the MDCP/DBMD Escalation Help Line?

The MDCP/DBMD Escalation Help Line assists people with Medicaid who get benefits through the Medically Dependent Children Program (MDCP) or the Deaf Blind with Multiple Disabilities (DBMD) program.

The MDCP/DBMD Escalation Help Line can help you solve issues related to the STAR Kids managed care program. Such help includes answering questions about Medicaid fair hearings and continuing services while appealing a service denial.

When should I call the MDCP/DBMD Escalation Help Line?

Call when you have tried to get help but have not been able to get the help you need. If you don’t know who to call, you can call 844-999-9543, and someone will work to connect you with the right people.

Is the MDCP/DBMD escalation help line the same as the HHS Office of the Ombudsman?

No. The MDCP/DBMD escalation help line is dedicated to individuals and families that receive benefits from the MDCP or DBMD program.

Who can call the MDCP/DBMD escalation help line?

You, your authorized representative, and your legal representative can call.

Can I call any time?

You can call the MDCP/DBMD escalation help line and speak with someone Monday through Friday from 8 a.m. – 8 p.m. You can call after these hours and leave a message, and one of our trained on-call staff will call you back as soon as possible.

What is an appeal?

An appeal is the formal process by which a Member or his or her representative requests a review of DentaQuest's actions.

What can I do if DentaQuest denies or limits a service for my child that the dentist has asked for?

If you do not agree with DentaQuest's decision on your dental services, you may request an appeal.

How will I find out if services for my child are denied?

We will send you and your dentist a letter. You can also call our Member Call Center and we can tell you the status of your appeal. Call us at 1-800-516-0165.

What are the timeframes for the appeal process?

You must ask for an appeal within 60 calendar days after DentaQuest sends you a decision or action about your original complaint. To make sure your child continues to get his/her current dental services, you must file your appeal within 10 business days after you get DentaQuest’s decision to your complaint. This ensures that DentaQuest gets your appeal before the effective date of their decision or action to your original complaint.

When can I ask for an appeal?

You have the right to ask for an appeal if you disagree with DentaQuest's decision or action. You can also ask for an appeal for partial or complete denial of payment for services. You must ask for an appeal within 60 calendar days after DentaQuest sends you a decision or action. To make sure your child continues to get his/her current dental services, you must file your appeal on or before the later of: 10 calendar days following DentaQuest's mailing of the notice of action or the intended effective date of the proposed action. Either you or DentaQuest can request one, 14 calendar day extension. If DentaQuest requests an extension, it will do so in writing and must show the need for more information and how the delay is in your interest.

How do I ask for an appeal?

You can call DentaQuest to ask for an appeal. The toll-free number is 1-800-516-0165. Within five (5) business days after you call, we will send you an appeal form. You can also mail DentaQuest your appeal to:

DentaQuest TX Dental Services
P.O. Box 2906
Milwaukee, WI 53201-2906
ATTN: Appeals Department

You may use this form if you would like to write to us:

TX Medicaid Appeal Form

Our address to mail your appeal to is:

DentaQuest TX Dental Services
P.O. Box 2906
Milwaukee, WI 53201-2906
ATTN: Appeals Department

Can I just ask for an appeal or does it have to be in writing?

Every time someone asks for an appeal, that request must be written and signed by the person getting the Medicaid coverage or his or her representative, unless the person asks for an Expedited Appeal, which can be spoken or written.

Can my dentist ask for an appeal?

You, your child's dentist, or someone that represents you can ask for an appeal. However, you will need to give your consent in writing to have another person request your appeal.

Can someone from DentaQuest help me file an appeal?

Yes. Please call our member call center for help. The toll-free number is 1-800-516-0165. Tell us that you want to file an appeal. After you have filed your appeal, DentaQuest will mail you an appeal form to complete.

What do I do when I get the appeal form from DentaQuest?

You, your child's dentist, or someone that represents you can fill out the form and mail it back to us. Again, you will need to give your consent in writing to have another person request your appeal. If your appeal request is for a dental emergency, we do not need a completed, signed form to process the appeal.

How soon will I hear back from DentaQuest after I mail my appeal form?

We will respond to your appeal within 30 calendar days from the day we receive your appeal form. You or DentaQuest can ask for an extension of up to 14 calendar days if there is a need for more information to make a decision. DentaQuest will send you a written notice to tell you the reason for the delay.

What else can I do if I'm still not happy?

You or someone you name to act for you may file a request for external review within four months of receiving our appeal resolution letter. To ask for an IRO, you must fill out the “HHS Administered Federal External Review Request Form” that will be included with the appeal resolution letter. If you want to send more information to include in the review, you can send it with your request. You don’t have to pay for this review or any filing fees. If you would like to have another person make an external review request on your behalf, both you and your authorized representative will need to complete and sign the Appointment of Representative Form (under the “Forms” heading). Our address to mail your form is:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Fax: 1-888-866-6190

Online: Request a review online at externalappeal.com. If you believe your case is urgent and should be expedited, you can select “expedited” if submitting the review request online, or by emailing FERP@maximus.com, or calling Federal External Review Process at 1-888-866-6205, ext. 3326. MAXIMUS Federal Services will provide notice of the final external review decision as expeditiously as your medical conditions or circumstances require, but in no event more than 72 hours after they receive a request for an expedited external review. When MAXIMUS Federal Services receives your request, they will notify us, and we’ll send them all the case information for review. If you send them any more information they’ll share it with us. We may change our decision. If not, the IRO will continue the review. You’ll receive a letter with their decision for a standard request no later than 45 days after they receive the request for the external review. If MAXIMUS Federal Services decides to overturn our decision, we will provide coverage or payment for your health care items or services.

If you have questions or concerns about your external review, call 1-888-866-6205.

What is an Emergency Appeal?

Ask for an Emergency Appeal when you don’t have time for a standard appeal – when your child’s life or health is in danger. When you ask for an emergency appeal, DentaQuest has to make a decision quickly based on the condition of your child’s health.

How do I ask for an Emergency Appeal?

You can call us to file an emergency appeal. If you need help to file an emergency appeal, call our member call center for help. The toll-free number is 1-800-516-0165. Call us and tell us that you want to file an emergency appeal. We do not need your appeal in writing for an emergency appeal.

How long does an Emergency Appeal take?

We will make a decision within three (3) business days after we get your emergency appeal. We will call you with the decision. We will also send you a letter within two (2) business days of the decision.

What happens if DentaQuest says it won't do an Emergency Appeal?

If DentaQuest does not think your appeal is life-threatening, we will let you know the same day that the decision is made. DentaQuest will make this decision within three (3) business days. Your appeal will still be worked on, but the decision may take up to 30 days.

Who can help me file an Emergency Appeal?

If you need help asking for an emergency appeal, call us toll-free at 1-800-516-0165 and a Member Advocate will help you.

Can I ask for a State Fair Hearing?

If you, as a Member of the dental plan, disagree with the dental plan’s decision, you have the right to ask for a State Fair hearing. You may name someone to represent you by writing a letter to DentaQuest telling them the name of the person you want to represent you. A provider may be your representative. If you want to challenge a decision made by DentaQuest, you or your representative must ask for the State Fair hearing within 120 days of the date on the dental plan’s letter of the decision being challenged. If you do not ask for the State Fair hearing within 120 days, you may lose your right to a State Fair hearing. To ask for a State Fair Hearing, you or your representative should either send a letter to DentaQuest at:

DentaQuest TX Dental Services
P.O. Box 2906
Milwaukee, WI 53201-2906
ATTN: Fair Hearing

You may use the State Fair Hearing and External Medical Review Request Form if you would like to write to us. 

For questions about the process or status of a state fair hearing, call toll free at 1-800-516-0165

If you ask for a State Fair Hearing within 10 days from the time you get the hearing notice from the dental plan, you have the right to keep getting any service the dental plan denied, at least until the final hearing decision is made. If you do not request a State Fair Hearing within 10 days from the time you get the hearing notice, the service DentaQuest denied will be stopped.

If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service DentaQuest denied.

HHSC will give you a final decision within 90 days from the date you asked for the hearing.

Can I ask for an External Medical Review?

If you, as a Member of the health dental plan, disagree with DentaQuest’s Internal Appeal decision, you have the right to ask for External Medical Review with fair hearing. An External Medical Review is an optional, extra step you can take to get your case reviewed for free before your state fair hearing. You, your parent, your authorized representative or your legally authorized representative (LAR) must ask for the External Medical Review within 120 days of the date the health plan mails the letter with the decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review.

To ask for an External Medical Review, you, your parent, your representative or your legally authorized representative should either:

• Fill out the ‘State Fair Hearing and External Medical Review Request Form’ that came with the Member Notice of MCO Internal Appeal Decision letter and mail or fax it to DentaQuest:

  DentaQuest
  P.O. Box 2906
  Milwaukee, WI  53201-2906

• Fax:  800-936-0913
• Call DentaQuest at 1-800-516-0165 (toll-free)

You have the right to keep getting any service the health plan denied or reduced, at least until the External Medical Review and final fair hearing decision is made if you ask for an External Medical Review with fair hearing by the later of: (1) 10 calendar days following the Dental Contractor’s mailing of the notice of the Action, or (2) the day the Dental Contractor’s letter says your service will be reduced or end. If you do not request continued benefits by this date, the service the dental plan denied will be stopped.

You may withdraw your request for an External Medical Review before it is assigned to an IRO or while the IRO is reviewing your External Medical Review request. An External Medical Review cannot be withdrawn if an IRO has already completed the review and made a decision.

Once the External Medical Review decision is received you have the right to withdraw the fair hearing request. If you continue with the fair hearing you can also request the IRO be present at the fair hearing. You can make both of these requests by contacting DentaQuest at 1-800-516-0165 (toll-free) or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

Can I Cancel My External Medical Review?

You may cancel your request for an External Medical Review before it is assigned to an IRO or while the IRO is reviewing your External Medical Review request. An External Medical Review cannot be canceled if an IRO has already completed the External Medical Review and made a decision.

Once the External Medical Review decision is received you have the right to cancel your State Fair Hearing request. If you continue with the State Fair Hearing you can also request the IRO be present at the State Fair Hearing. You can make both of these requests by contacting DentaQuest at 1-800-516-0165 or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

You can ask for an emergency state fair hearing if you feel your health will be seriously harmed by waiting for a decision. HHSC will review your case and determine if you qualify for an emergency state fair hearing. If your doctor supports your request, they should submit the support in writing to HHSC.

If you get an emergency state fair hearing, your hearing will be scheduled, and you will get a decision within three business days of your request. If you request an emergency external medical review with your emergency state fair hearing, you’ll get the external medical review decision within two business days. You can choose whether you want to have the state fair hearing you requested.