Texas HHSC Dental Services

DentaQuest USA Insurance Company, Inc. February 1, 2024

DentaQuest USA Insurance Company, Inc.

DentaQuest Provider Office Reference Manual

TX HHSC Dental Services‐ Medicaid and CHIP

Provider Manual

1-800-896-2374

www.dentaquest.com/texas

This document contains proprietary and confidential information and

may not be disclosed to others without written permission

Version 9.2

DentaQuest USA Insurance Company, Inc. February 1, 2024

DentaQuest USA Insurance Company, Inc. February 1, 2024 
 
Current Dental Terminology © American Dental Association. All Rights Reserved. 
2 
 
 
TABLE OF CONTENTS 
TX HHSC Dental Services‐ Medicaid and CHIP .......................................................................................................... 1 
Provider Manual ...................................................................................................................................................... 1 
TABLE OF CONTENTS ............................................................................................................................................... 2 
Introduction to DentaQuest ................................................................................................................................. 8 
Quick Reference Phone List ..................................................................................................................................... 8 
Program Objectives.................................................................................................................................................. 9 
Role of Main Dental Home ...................................................................................................................................... 9 
Are you building a “Dental Home” for your Members? ....................................................................................... 9 
Role of First Dental Home Initiative for Medicaid Members ................................................................................... 9 
Covered Services .................................................................................................................................................... 10 
Texas Health Steps Dental Services (Medicaid Only) ............................................................................................. 10 
Texas Health Steps Medical Checkup Periodicity Schedule for Infant, Children,
 
and Adolescents .......................... 10 
Exception to Periodicity Oral Evaluation, Dental Checkup, and Emergency or Trauma Related Services for Texas 
Health Steps Dental Procedures ............................................................................................................................ 12 
Exception-to-Periodicity Oral Evaluation ............................................................................................................... 12 
Exception-to-Periodicity Dental Checkup .............................................................................................................. 13 
Exception-to-Periodicity Emergency or Trauma Related Oral Evaluation ............................................................. 13 
Adjunctive General Services .................................................................................................................................. 13 
Children of Migrant Farmworkers ......................................................................................................................... 13 
Children’s Medicaid Dental Covered Services .......................................................................................................... 14 
Texas Medicaid Dental Program Covered Services include the following Medically Necessary  services. ........ 14 
CHIP Dental Covered Services .................................................................................................................................. 14 
Texas CHIP Dental Program Covered Services include the following Medically Necessary services. ................ 15 
C. Quality Management ......................................................................................................................................... 15 
Quality Improvement Program (Policies 200 Series) ............................................................................................. 15 
Utilization Management Program ......................................................................................................................... 16 
Introduction: ...................................................................................................................................................... 16 
Community Practice Patterns: ........................................................................................................................... 16 
Evaluation: ......................................................................................................................................................... 17 
Results: ............................................................................................................................................................... 17 
Network Management Program ............................................................................................................................ 17 
NETWORK MANAGEMENT PROCEDURES .......................................................................................................... 17 
D. Provider Responsibilities ................................................................................................................................... 19 
General Responsibilities......................................................................................................................................... 19 
Availability and Accessibility .............................................................................................................................. 20 
Main Dental Home Responsibilities ................................................................................................................... 20 
First Dental Home Initiative Responsibilities ..................................................................................................... 21 
Updates to Contact Information ........................................................................................................................ 22 
Plan Termination ................................................................................................................................................ 22 
Referral to Specialists Process............................................................................................................................ 22 
Referrals to Specialists .............................................................................................................................................. 22 
Verify Member Eligibility and/or Authorizations for Service ............................................................................. 23 
Member Eligibility .............................................................................................................................................. 23 
Access to eligibility information via the Provider Web Portal............................................................................ 24 
Access to eligibility information via the IVR line ................................................................................................ 25 
Authorizations of Service ................................................................................................................................... 25 
Submitting Authorization or Claims with X‐Rays ............................................................................................... 26 
Electronic Attachments ...................................................................................................................................... 27 
Continuity of Care .............................................................................................................................................. 28 

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Dental Records ................................................................................................................................................... 28 
Organization ............................................................................................................................................................. 28 
Compliance ............................................................................................................................................................... 32 
Health Insurance Portability and Accountability Act (HIPAA) ............................................................................ 32 
Access to Second Opinion .................................................................................................................................. 33 
Justification Regarding Out‐of‐Network Referrals ............................................................................................. 34 
Informed Consent for Utilization of Papoose Boards ........................................................................................ 34 
Routine, Therapeutic/Diagnostic, and Urgent Care Dental Services ..................................................................... 35 
Definitions .......................................................................................................................................................... 35 
EMERGENCY Treatments and Authorizations .................................................................................................... 36 
Requirements for Scheduling of Appointments ................................................................................................. 36 
Coordination of Non‐Capitated Services ............................................................................................................... 36 
Medicaid Services Not Covered by DentaQuest ................................................................................................ 36 
MEDICAL TRANSPORTATION PROGRAM (MTP) ................................................................................................. 37 
CHIP Services Not Covered by DentaQuest ........................................................................................................ 37 
Effective January 1, 2019 - Retro eligibility Recoupment Process ..................................................................... 38 
Provider Appeal Process to HHSC (related to claim recoupment due to Member disenrollment) .......................... 38 
E. Medicaid Dental Services Provider Complaint and Appeal Process .................................................................... 38 
Medicaid Provider Complaints ............................................................................................................................... 39 
Medicaid Provider Appeals .................................................................................................................................... 39 
Peer to Peer Reviews ............................................................................................................................................. 40 
F. Medicaid Dental Services Member Complaint and Appeal Process .................................................................... 40 
Medicaid Member Complaint ................................................................................................................................ 40 
What should I do if I have a complaint? ............................................................................................................. 40 
If the Member is not satisfied with the outcome, who else can they call? ....................................................... 41 
MDCP/DBMD ESCALATION HELP LINE .................................................................................................................... 41 
What is the MDCP/DBMD Escalation Help Line? ................................................................................................... 41 
When should I call the escalation help line? ......................................................................................................... 41 
Is the escalation help line the same as the HHS Office of the Ombudsman? ........................................................ 41 
Who can call the help line? .................................................................................................................................... 42 
Medicaid Member Appeals .................................................................................................................................... 42 
What can I do if DentaQuest denies or limits my Member’s request for a covered service? ............................. 42 
How will I find out if services are denied? .......................................................................................................... 42 
Timeframes for the Appeal Process ................................................................................................................... 42 
When does the Member have the right to ask for an appeal? ........................................................................... 43 
Can someone from DentaQuest help a Member file an appeal? ....................................................................... 43 
Medicaid Member Expedited Appeals ................................................................................................................... 43 
How to Request an Emergency Appeal .............................................................................................................. 43 
Timeframes for Emergency Appeals .................................................................................................................. 43 
What happens if DentaQuest denies the request for an Emergency Appeal? ................................................... 43 
Who can help me file an Emergency Appeal? .................................................................................................... 44 
State Fair Hearing Information .............................................................................................................................. 44 
Can a Member ask for a State Fair Hearing? ...................................................................................................... 44 
External Medical Review Information .................................................................................................................... 44 
Can a Member ask for an External Medical Review? ............................................................................................ 44 
Can a Member ask for an emergency External Medical Review? .......................................................................... 45 
G. CHIP Provider Complaints and Appeals .............................................................................................................. 46 
CHIP Provider Complaints ...................................................................................................................................... 46 
CHIP Provider Appeals ........................................................................................................................................... 46 
Peer to Peer Reviews ............................................................................................................................................. 47 
“Like Specialty” Peer to Peer Reviews ................................................................................................................... 47 

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Procedure ........................................................................................................................................................... 47 
CHIP Member Complaints and Appeals ................................................................................................................. 48 
CHIP Member Complaint ................................................................................................................................... 48 
What should I do if I have a complaint? ............................................................................................................. 49 
Who do I call? ..................................................................................................................................................... 49 
Can someone from DentaQuest help a Member file a complaint? .................................................................... 49 
How long will it take to investigate and resolve my complaint? ........................................................................ 49 
If I am not satisfied with the outcome, who else can I call? .............................................................................. 50 
CHIP Member Appeal ............................................................................................................................................ 50 
What can I do if DentaQuest denies or limits my patient’s request for a covered service? ............................... 50 
How will I find out if the appeal is denied? ........................................................................................................ 51 
Timeframes for the Appeal Process ................................................................................................................... 52 
When does a Member have the right to request an appeal? ............................................................................. 52 
Can someone from DentaQuest help the Member file an appeal? .................................................................... 53 
CHIP Member Expedited Appeals .......................................................................................................................... 53 
How to Request an Expedited Appeal ................................................................................................................ 53 
Timeframes for Expedited Appeals .................................................................................................................... 53 
What happens if DentaQuest denies the request for an Expedited Appeal? ..................................................... 53 
Who can help me file an Expedited Appeal? ...................................................................................................... 53 
Independent Review Organization (IRO) for External CHIP Appeal Reviews ......................................................... 54 
What is an Independent Review Organization? ................................................................................................. 54 
How do I request a review by an Independent Review Organization? ............................................................... 54 
HHS‐Administered Federal External Review Request Form ............................................................................... 54 
HHS Federal External Review Process Appointment of Representative Form ................................................... 54 
How long will it take to investigate and resolve my external appeal? ............................................................... 55 
Standard External Review requests: .................................................................................................................. 55 
Expedited Independent Review Organization request ...................................................................................... 55 
How long will it take to investigate and resolve my expedited external appeal? .............................................. 56 
For an expedited External Review request: ....................................................................................................... 56 
HHSC Oversight ...................................................................................................................................................... 56 
H. Medicaid Member Eligibility and Added Benefits .............................................................................................. 56 
Eligibility ................................................................................................................................................................. 56 
Verifying Eligibility ................................................................................................................................................. 56 
Main Dental Home Verification ......................................................................................................................... 56 
DentaQuest Member Identification Card .......................................................................................................... 57 
Call DentaQuest ................................................................................................................................................. 57 
Automated Inquiry System line/TXMedConnect ............................................................................................... 57 
Automatic Re‐enrollment ...................................................................................................................................... 58 
Disenrollment ........................................................................................................................................................ 58 
Can DentaQuest ask that my child get dropped from their dental plan? .......................................................... 58 
Medicaid Plan Changes .......................................................................................................................................... 58 
Medicaid Added Benefits ....................................................................................................................................... 59 
Medicaid Member Value Added Services .............................................................................................................. 59 
Additional value‐added services: .............................................................................................................................. 59 
I. CHIP Member Eligibility and Added Benefits ....................................................................................................... 60 
Eligibility ................................................................................................................................................................. 60 
Verifying Eligibility ................................................................................................................................................. 60 
DentaQuest CHIP Identification Card ................................................................................................................. 60 
Re‐enrollment ........................................................................................................................................................ 61 
Disenrollment ........................................................................................................................................................ 61 
Can DentaQuest ask that my child get dropped from their dental plan? .......................................................... 61 
CHIP Plan Changes ................................................................................................................................................. 61 

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CHIP Added Benefits .............................................................................................................................................. 62 
CHIP Member Value Added Services ...................................................................................................................... 62 
Member Rights and Responsibilities ...................................................................................................................... 63 
MEMBER RIGHTS ................................................................................................................................................... 63 
Medicaid Member Responsibilities ....................................................................................................................... 65 
CHIP DENTAL SERVICES MEMBER RIGHTS AND RESPONSIBILITIES........................................................................ 66 
CHIP Member Rights .............................................................................................................................................. 66 
CHIP Member Responsibilities ............................................................................................................................... 68 
Fraud and Abuse Reporting ................................................................................................................................... 68 
Do you want to report Waste, Abuse, or Fraud? ............................................................................................... 68 
To report waste, abuse, or fraud, choose one of the following: ........................................................................ 69 
To report waste, abuse or fraud, gather as much information as possible. ...................................................... 69 
J. Medicaid and CHIP Encounter Data, Billing, and Claims Administration ............................................................. 69 
Where to Send Claims/Encounter Data ................................................................................................................. 69 
Electronic Claim Submission Utilizing DentaQuest’s Internet Website ............................................................. 70 
Electronic Authorization Submission Utilizing DentaQuest's Internet Website ................................................ 70 
Electronic Claim Submission via Clearinghouse ................................................................................................. 71 
HIPAA Compliant 837D File ................................................................................................................................ 71 
NPI Requirements for Submission of Electronic Claims ..................................................................................... 71 
Paper Claim Submission ..................................................................................................................................... 71 
Coordination of Benefits (COB) .......................................................................................................................... 72 
Receipt and Audit of Claims ............................................................................................................................... 73 
Second Opinion Reviews and Regional Screening ............................................................................................. 73 
Form to Use ........................................................................................................................................................... 73 
CHIP Cost Sharing Schedule ................................................................................................................................... 73 
No Co‐Payments for Medicaid Members .............................................................................................................. 75 
Billing Members ..................................................................................................................................................... 75 
Member Acknowledgement Statement ............................................................................................................. 75 
Private Pay Form Agreement ............................................................................................................................. 75 
Time Limit for Submission of Claims/Claims Appeals ............................................................................................ 75 
Claims Payment ..................................................................................................................................................... 76 
K. Medicaid and CHIP Special Access Requirements ............................................................................................... 76 
Interpreter/Translation Services ............................................................................................................................ 76 
Dental Contractor/Provider Coordination ............................................................................................................. 77 
Reading/Grade Level Consideration ...................................................................................................................... 77 
Cultural Sensitivity ................................................................................................................................................. 77 
Knowledge .......................................................................................................................................................... 78 
Skills.................................................................................................................................................................... 78 
Attitudes............................................................................................................................................................. 78 
Specialty Health Care Needs .................................................................................................................................. 79 
L. DentaQuest Information .................................................................................................................................... 79 
Standard of Care .................................................................................................................................................... 79 
Identical Restoration: (same tooth, exact same service), same provider or location (Prior Authorization or Pre-
Payment Review) ............................................................................................................................................... 79 
Similar Restoration: (same tooth, at least one surface repeated), same provider or location (Prior 
Authorization or Pre-Payment Review) ............................................................................................................. 80 
Provider Preventable Conditions ........................................................................................................................... 81 
Professional Conduct ............................................................................................................................................. 81 
Credentialing (Policies PEC Series) ......................................................................................................................... 81 
Credentials Committee Denials (Policy PEC01)...................................................................................................... 82 
Recredentialing (Policy PEC01) .............................................................................................................................. 82 
Disciplinary Actions, Corrective Action Plans & Provider Appeals (Policy PEC05) ................................................. 82 
Appeal of Credentials Committee Termination (Policy PEC05) ............................................................................. 82 

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Broken Appointments – Best Practices .................................................................................................................. 82 
Logging Broken Appointments in the Provider Web Portal ................................................................................... 83 
Direct Deposit ........................................................................................................................................................ 84 
Advance Directives ................................................................................................................................................ 85 
Clinical Criteria ....................................................................................................................................................... 86 
Criteria for Dental Extractions ............................................................................................................................ 87 
Documentation needed for authorization procedure: ...................................................................................... 87 
Criteria................................................................................................................................................................ 87 
Criteria for Cast Crowns ..................................................................................................................................... 87 
Documentation needed for authorization of procedure: .................................................................................. 87 
Criteria................................................................................................................................................................ 88 
Criteria for Endodontics ..................................................................................................................................... 88 
Documentation needed for authorization of procedure: .................................................................................. 89 
Criteria................................................................................................................................................................ 89 
Criteria for Stainless Steel Crowns ..................................................................................................................... 90 
Documentation needed for authorization of procedure: .................................................................................. 90 
Criteria................................................................................................................................................................ 90 
Criteria for Authorization of Operating Room (OR) Cases Documentation needed for authorization of 
procedure: .......................................................................................................................................................... 91 
Criteria................................................................................................................................................................ 91 
Criteria for Removable Prosthodontics (Full and Partial Dentures) ................................................................... 92 
Documentation needed for authorization of procedure: .................................................................................. 92 
Criteria................................................................................................................................................................ 92 
Criteria................................................................................................................................................................ 93 
Criteria for the Excision of Bone Tissue .............................................................................................................. 94 
Criteria for the Determination of a Non‐Restorable Tooth ............................................................................... 94 
Criteria for General Anesthesia and Intravenous (IV) Sedation
 
Documentation needed for authorization of 
procedure: .......................................................................................................................................................... 95 
Criteria................................................................................................................................................................ 95 
For Members Ages Six and Under ...................................................................................................................... 96 
Dental Anesthesiologist ..................................................................................................................................... 97 
Treating Dentist.................................................................................................................................................. 97 
Medical Anesthesiologist ................................................................................................................................... 98 
Treating Dentist.................................................................................................................................................. 98 
Medical Anesthesiologist and / or Facility ......................................................................................................... 99 
Treating Dentist.................................................................................................................................................. 99 
Criteria for Periodontal Treatment .................................................................................................................... 99 
Criteria.............................................................................................................................................................. 100 
Appendix A
 
Definitions ........................................................................................................................................ 101 
Appendix B Forms to Use ..................................................................................................................................... 103 
Non‐Covered Service Disclosure Form ................................................................................................................. 106 
OrthoCAD Submission Form ................................................................................................................................. 107 
Continuation of Care Submission Form ................................................................................................................ 108 
Children’s Medicaid Dental Services Managed Care Orthodontia Review Policy and Procedure‐ Texas ............... 109 
Purpose ................................................................................................................................................................ 109 
Definitions ............................................................................................................................................................ 109 
Policy .................................................................................................................................................................... 109 
RECALL EXAMINATION ......................................................................................................................................... 120 
RECALL EXAMINATION ......................................................................................................................................... 120 
Authorization for Dental Treatment .................................................................................................................... 121 
MEDICAL AND DENTAL HISTORY .......................................................................................................................... 122 
AUTHORIZATION TO HONOR DIRECT AUTOMATED CLEARING HOUSE (ACH) CREDITS DISBURSED BY DENTAQUEST 
USA‐TX HHSC Dental Services Program ................................................................................................................ 124 

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INSTRUCTIONS ..................................................................................................................................................... 124 
MAINTENANCE TYPE: ........................................................................................................................................... 124 
ACCOUNT HOLDER INFORMATION: ..................................................................................................................... 124 
APPENDIX C ......................................................................................................................................................... 125 
Covered Benefits (See Exhibits) ........................................................................................................................... 125 
800.896.2374, press option 2 .......................................................................................................................... 125 
DentaQuest Authorization Process ...................................................................................................................... 127 
IMPORTANT ......................................................................................................................................................... 127 
Exhibit A Benefits Covered for TX Medicaid Child (Under 21)............................................................................... 128 

DentaQuest USA Insurance Company, Inc. February 1, 2024

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Introduction to DentaQuest

Quick Reference Phone List

Provider Services‐Medicaid and CHIP

1‐800‐896‐2374

Monday – Friday; 8 a.m. – 6 p.m.

Fax numbers:

Claims/payment issues: 262‐241‐7379

Claims to be processed: 262‐834‐3589

All other: 262‐834‐3450

Claims Questions:

[email protected]

Medicaid Member Services

1‐800‐516‐0165

Monday – Friday; 8 a.m. – 6 p.m.

CHIP Member Services

1‐800‐508‐6775

Monday – Friday; 8 a.m. – 6 p.m.

TTY Service

Federal Relay Service 7‐1‐1

TMHP Contact Center/Automated Inquiry

System (AIS)

1‐800‐925‐9126 or 512‐335‐5986

www.tmhp.com

*For interpretation/translation services,

please contact the Provider Services

Department at:

1‐800‐896‐2374

Authorizations should be sent to:

TX HHSC Dental Program‐ Authorization

P.O. Box 2906 Milwaukee,

WI 53201‐2906

Fax: 262‐241‐7150 or 888‐313‐2883

Credentialing applications should be sent

to:

TX HHSC Dental Program‐ Credentialing

P.O. Box 2906 Milwaukee,

WI 53201‐2906

Credentialing Hotline: 800.233.1468

Fax: 262‐241‐4077

Claims should be sent to:

TX HHSC Dental Program –Claims

Box 2906 Milwaukee, WI 53201‐2906

Electronic Claims should be sent:

Direct entry on the web –

www.dentaquest.com

Or,

Via Clearinghouse – Payer ID CX014

Include address on electronic claims –

DentalQuest, LLC

PO Box 2906

Milwaukee, WI 53201-2906

DentaQuest USA Insurance Company, Inc. February 1, 2024

Program Objectives

The primary objective of Texas Medicaid and CHIP Dental Services programs are to create a

comprehensive dental care system offering quality dental services to those eligible Texas

residents. We emphasize early intervention and promote access to care, thereby improving

health outcomes for Texas residents.

Role of Main Dental Home

Are you building a “Dental Home” for your Members?

Effective March 1, 2012, DentaQuest USA Insurance Company, Inc. (DentaQuest) implemented

the Dental Home program in Texas for Medicaid and CHIP Members.

The Main Dental Home is a place where a child’s oral health care is delivered in a complete,

accessible and family‐centered manner by a licensed dentist. This concept has been

successfully

employed by primary care physicians in developing a “Medical Home” for their Members, and

the “Dental Home” concept mirrors the “Medical Home” for primary dental and oral health care.

If expanded or specialty dental services are required, the dentist is not

expected to deliver the

services, but to coordinate the referral and to monitor the outcome.

Provider support is essential to effectively employ the Dental Home program for Medicaid and

CHIP Dental Program Members. With assistance and support from dental professionals, a system

for improving the overall health of children in the Medicaid and CHIP Programs can be

achieved.

Main Dental Home assignment must be verified on the DentaQuest Provider Web Portal (located

in the “Providers Only” section of DentaQuest’s website at www.dentaquest.com. You may also

contact DentaQuest’s Customer Service Department at 1‐800‐896‐2374 to verify

Main Dental

Home assignment.

Role of First Dental Home Initiative for Medicaid Members

Medicaid Members from six (6) through 35 months of age may be seen for dental checkups by a

certified First Dental Home Initiative provider as frequently as every sixty (60) days if medically

necessary.

Providers must be certified to be a Texas Health Steps Dentist. To become a First Dental Home

Initiative Provider (Texas Health Steps), the dentist must complete the online module and submit

both the training certificate and the First Dental Home certification application form.

DentaQuest USA Insurance Company, Inc. February 1, 2024

The Texas Health Steps online First Dental Home Module is available at

www.txhealthsteps.com.

Go to “Start a free course now” and choose “First Dental Home” from

the drop down menu.

For additional information regarding the Dental Home program, please connect to the

DentaQuest Provider Web Portal www.dentaquest.com under Related Documents – Dental

Home.

Only certified, participating First Dental Home Providers may bill a D0145 for a first dental home

oral evaluation. The member is only allowed one of D0120 or D0150 in a six month period.

D1330, D1206, and D1208 will be denied when billed on the same date of service as D0145.

Covered Services

Texas Health Steps Dental Services (Medicaid Only)

Texas Health Steps is the Texas version of the Medicaid program known as Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT). Texas Health Steps dental services are mandated

by Medicaid to provide for the early detection and treatment of dental health problems for

Medicaid‐eligible members who are from birth through 20 years of age. Texas Health Steps

dental service standards are designed to meet federal regulations and incorporate the

recommendations of representatives of national and state dental professional organizations.

Texas Health Steps’ designated staff (Texas Department of State Health Services [DSHS],

Department of Assistive and Disability Services [DADS], or contractor), through outreach and

informing, encourage eligible children to use Texas Health Steps dental checkups and services

when children first become eligible for Medicaid, and each time children are periodically due for

their next dental checkup.

Please refer to the Texas Medicaid Provider Procedures Manual for more information regarding

Texas Health Steps dental services:

Go to www.tmhp.com. Click on “Providers” at the top of the screen, then “Reference Material”

on the left hand side.

Texas Health Steps Medical Checkup Periodicity Schedule for Infant, Children,

and Adolescents

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Exception to Periodicity Oral Evaluation, Dental Checkup, and Emergency or

Trauma Related Services for Texas Health Steps Dental Procedures

Oral evaluations and dental checkups allow for the early diagnosis and treatment of dental

problems. They might be needed at more frequent intervals than noted in the periodicity

schedule.

If needed, a dental checkup or oral evaluation can still be reimbursed when the service falls

outside the periodicity schedule. The rules for such exceptions are outlined below.

Exception-to-Periodicity Oral Evaluation

A Texas Health Steps exception-to-periodicity oral evaluation is limited to

dental procedure code D0120.

An exception-to-periodicity oral evaluation is allowed when the service is:

• Medically necessary and based on risk factors and health needs for members birth

through 6 months of age.

• Mandated service required to meet federal or state exam requirements for Head Start,

daycare, foster care or preadoption.

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Providers must include all appropriate procedure codes on the dental claim submission form.

Providers would need to include a narrative and comment in box 35.

Exception-to-Periodicity Dental Checkup

A Texas Health Steps exception-to-periodicity dental checkup is allowed

when:

• The member will not be available for the next periodically due dental checkup. This

includes members whose parents are migrant or seasonal workers.

• For members whose parents are migrant or seasonal workers and need the accelerated

services, include “Exception” in block 35, “Remark” field.

Providers must include all appropriate procedure codes on the dental claim

submission form.

Exception-to-Periodicity Emergency or Trauma Related Oral Evaluation

A Texas Health Steps exception-to-periodicity emergency or trauma related oral evaluation is

limited to dental procedure code D0140.

Procedure code D0140 is limited to once per day for the same provider and twice per day for any

provider.

A Texas Health Steps exception-to-periodicity emergency or trauma related dental service will be

allowed when the service is:

• Required for immediate treatment and any follow-up treatment.

• Required for therapeutic services needed to complete a case for members, 5 months of

age and younger, when initiated as emergency services, trauma, or early childhood caries.

When submitting a claim for emergency or trauma related dental services, the provider must

include:

• “Trauma” or “Emergency” in Block 35, “Remark” field

• The original date of treatment or incident in Block 35, “Remark” field

Providers must include all appropriate procedure codes on the dental claim submission form.

Adjunctive General Services

When submitting a claim for an unclassified treatment procedure code D9110

the provider must include:

• “Trauma” or “Emergency” in Block 35, “Remark” field

• The original date of treatment or incident in Block 35, “Remark” field

Providers must include all appropriate procedure codes on the dental claim submission form.

Children of Migrant Farmworkers

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Children of Migrant Farm workers due for a Texas Health Steps medical checkup can receive

their

periodic checkup on an accelerated basis prior to leaving the area. A checkup performed under

this circumstance is an accelerated service but should be billed as a checkup.

Providers must include all appropriate procedure codes on the dental claim along with

“Exception” & “FWC or Farm Worker Child” in Block 35, “Remark” field.

Performing a make‐up exam for a late Texas Health Steps medical checkup previously missed

under the periodicity schedule is not considered an exception to periodicity nor an accelerated

service. It is considered a late checkup.

Children’s Medicaid Dental Covered Services

Texas Medicaid Dental Program benefits are subject to the same benefit limits and exclusions

that apply to Traditional Medicaid, but are not subject to the maximum fees imposed under

Traditional Medicaid. For a complete list of the limitations and exclusions that apply to each

Medicaid benefit category, refer to the current Texas Medicaid Provider Procedures Manual

(TMPPM), which can be accessed online at: http://www.tmhp.com For informational purposes

only, the maximum fees for Traditional Medicaid are located in the Texas Medicaid Fee

Schedule

in the TMPPM and online at http://public.tmhp.com/FeeSchedules/Default.aspx

The following is a non‐exhaustive, high‐level list of Covered Services in the Texas Medicaid

Dental Program. Covered Services are subject to modification based on changes in federal and

state laws, rules, regulations, and policies.

Texas Medicaid Dental Program Covered Services include the following Medically Necessary

services.

• Diagnostic and preventive

• Therapeutic

• Restorative

• Endodontic

• Periodontal

• Prosthodontic (removable and fixed)

• Implant and oral and maxillofacial surgery

• Orthodontic

• Adjunctive general

CHIP Dental Covered Services

Covered Dental Services are subject to a $564 annual benefit limit unless an exception applies. In

addition, some of the benefits identified in the schedule below are subject to annual limits.

Limitations are based on a 12‐month coverage period.

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CHIP Members who have exhausted the $564 annual benefit limit continue to receive the

following Covered Dental Services in excess of the $564 annual benefit maximum:

(1) The diagnostic and preventive services due under the 2009 American Academy of

Pediatric Dentistry periodicity schedule; and

(2) Other Medically Necessary Covered Dental Services approved by the Dental Contractor

through a prior authorization process. These services must be necessary to allow a CHIP

Member to return to normal, pain and infection‐free oral functioning. Typically, this

includes:

• Services related to the relief of significant pain or to eliminate acute infection;

• Services that allow the CHIP Member to attain the basic human functions (e.g., eating,

speech); and

• Services that prevent a condition from seriously jeopardizing the CHIP Member’s

health/functioning or deteriorating in an imminent timeframe to a more serious and

costly dental problem.

Texas CHIP Dental Program Covered Services include the following Medically Necessary

services.

• Diagnostic and preventive

• Therapeutic

• Restorative

• Endodontic

• Periodontal

• Prosthodontic

• Oral and maxillofacial surgery

Note: If a Member is undergoing a course of treatment, the Covered Services terminate on the

Date of Disenrollment.

Refer to the most recent version of the Code on Dental Procedures and Nomenclature for coding

that applies to Covered Dental Services.

C. Quality Management

Quality Improvement Program (Policies 200 Series)

DentaQuest currently administers a Quality Improvement Program modeled after National

Committee for Quality Assurance (NCQA) standards. The NCQA standards are adhered to as

practice guidelines to dental managed care. The Quality Improvement Program includes but is

not limited to:

• Provider credentialing and re‐credentialing.

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• Member satisfaction surveys.

• Provider satisfaction surveys.

• Random Chart Audits.

• Complaint Monitoring and Trending.

• Peer Review Process.

• Utilization Management and practice patterns.

• Initial Site Reviews and Dental Record Reviews.

• Quarterly Quality Indicator tracking (i.e. complaint rate, appointment waiting

time, access to care, etc.)

A copy of DentaQuest’s Quality Improvement Program is available upon request by contacting

DentaQuest’s Customer Service department at 1‐800‐896‐2374

Utilization Management Program

Introduction:

Reimbursement to dentists for dental treatment rendered can come from any number of sources

such as individuals, employers, insurance companies and local, state or federal

government. The

source of dollars varies depending on the particular program. For example,

in traditional

insurance, the dentist reimbursement is composed of an insurance payment and a patient

coinsurance payment. In State Medical Assistance Dental Programs (Medicaid), the

State

Legislature annually appropriates or “budgets” the amount of dollars available for

reimbursement to the dentists as well as the fees for each procedure. Since there is usually no

patient co‐payment, these dollars represent all the reimbursement available to the dentist.

These “budgeted” dollars, being limited in nature, make the fair and appropriate distribution to

the dentists of crucial importance.

Community Practice Patterns:

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.

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Evaluation:

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.

• Treatment cost effectiveness.

Results:

With the objective of ensuring the fair and appropriate distribution of these budgeted Medicaid

Dental Program dollars to dentists, DentaQuest’s Utilization Management Programs will help

identify those dentists whose patterns show significant deviation from the normal practice

patterns of the community of their peer dentists (typically less than 5% of all dentists). When

presented with such information, dentists will implement slight modification of their diagnosis

and treatment processes that bring their practices back within the normal range. However, in

some isolated instances, it may be necessary to recover reimbursement.

Network Management Program

DentaQuest maintains a program of ongoing monitoring efforts, specific quality and claim

reviews, and other network management initiatives to ensure that its professional service

providers deliver appropriate services within the standard of care and adhere to appropriate cost

and efficiency standards as developed through applicable laws, regulations, contracts, policies,

and procedures. DentaQuest evaluates, among other items, quality, cost, efficiency standards,

claims data, and provider behavioral patterns.

NETWORK MANAGEMENT PROCEDURES

The Network Management Team, Peer Review Committee, Credentialing Committee, Utilization

Oversight Program (UOP), Fraud, Prevention and Recovery team, or other DentaQuest staff may

use DentaQuest’ s data to identify those providers that may be candidates for one or more

network management actions. Each provider may be reviewed further, as appropriate, to

evaluate the quality of care and claim history of that provider.

1. DentaQuest may conduct monitoring, targeted reviews, educational sessions or invoke other

network management initiatives as described in more detail below, including without

limitation, intermediate sanctions or terminations upon determining, in its sole discretion,

that one or more of the following has occurred:

a. Failure to maintain a safe environment for Members and/or DentaQuest provider

representatives

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b. Harassment, discrimination, abuse, inappropriate or unprofessional conduct of or

against a member or a DentaQuest staff member or employee

c. Dental board actions, indictment, or misdemeanor complaint related to the practice

of dentistry

d. More than three (3) substantiated member complaints or grievances within a one-

year period

e. Initiation of one or more clinical audits conducted by Fraud, Prevention and Recovery

that results in Fraud, Waste or Abuse (FWA) findings

f. Referral of the provider to Fraud Prevention and Recovery for a full clinical review

that results in FWA findings

g. Failure to behavior modify after receiving a UOP letter from Fraud Prevention and

Recovery

h. Failure to behavior modify after investigation by Fraud Prevention and Recovery

i. More than three (3) alerts issued to provider under DentaQuest’s UOP within a six-

month period

j. Provision of services by any provider that are determined by DentaQuest in its sole

discretion to be excessive, unnecessary, contraindicated, or indicative of prior failed

services

k. Failure to satisfy established pay for quality (P4Q) metrics

l. More than seventy percent (70%) percent of claims for the same or similar service

denied or adjusted downward within a six-month period

m. Multiple submissions of authorization requests for the same service, same provider or

location on the same day

n. Multiple submissions of authorization requests for the same service, same provider,

same location without providing new supporting information

o. Failure to submit appropriate documentation with authorization requests after being

informed by DentaQuest of the supporting documentation requirements

p. Conviction of any crime of moral turpitude, with conviction defined in accordance

with 42 C.F.R. § 455.2

q. Occurrence of any event set forth in 42 C.F.R. Part 1001, Subparts B or C

r. Noncompliance with terms of the Dental Provider Service Agreement

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s. Noncompliance with terms of the Office Reference Manual (ORM)

2. DentaQuest will initiate mandatory educational sessions upon determining that any of the

events identified in Section 1(j) through 1(o) has occurred and may, in its sole discretion,

offer the provider an opportunity to cure before imposing further intermediate sanctions.

3. Upon determining that any of the events in Section 1 have occurred, DentaQuest, in its sole

and absolute discretion may take any one or more of the following network management

actions:

a. Adjust or recoup future payments to correct overpayments

b. Require refunds to correct overpayments

c. Require a Corrective Action Plan

d. Invoke targeted prior authorizations

e. Invoke utilization oversight periods

f. Require mandatory training or education

g. Place restrictions on network participation

h. Place restrictions or suspensions of Member assignments to dental home

i. Require advanced monitoring by DentaQuest

j. Require the use of an independent auditor at the provider’s expense

k. Suspension or Termination from a DentaQuest network

4. DentaQuest’s determination to initiate corrective action, intermediate sanctions or any

network management initiative is within its sole discretion. A determination not to invoke

network management initiatives or corrective action after an event or violation described in

Section 1 is not and should not be construed as a waiver of DentaQuest’s rights or remedies.

DentaQuest retains its right to employ network management initiatives and impose

corrective actions at any time.

D. Provider Responsibilities

General Responsibilities

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Availability and Accessibility

Each participating DentaQuest office is required to maintain and document a formal system for

patient recall. The system can utilize either written or phone contact. Any system should

encompass routine patient check‐ups, cleaning appointments, follow‐up treatment

appointments, and missed appointments for any health plan Member that has sought dental

treatment.

If a written process is utilized, the following language is suggested for missed appointments:

• “We missed you when you did not come for your dental appointment on month/date.

Regular check‐ups are needed to keep your teeth healthy.”

• “Please call to reschedule another appointment. Call us ahead of time if you cannot keep

the appointment. Missed appointments are very costly to us. Thank you for your help.”

Dental offices indicate that Medicaid Members sometimes fail to show up for appointments.

DentaQuest offers the following suggestions to decrease the “no show” rate.

• Contact the Member by phone or postcard prior to the appointment to remind the

individual of the time and place of the appointment.

• If the appointment is made through a government supported screening program,

contact

staff from these programs to ensure that scheduled appointments are kept.

Members should have the ability to receive direction from their provider on how to obtain

emergency services 24 hours a day, 7 days per week, including holidays and vacations.

Emergency appointments should be scheduled within 24 hours. The patient should be informed

that only the emergent condition will be treated at that time.

Members should not wait for more than fifteen (15) to thirty (30) minutes beyond their

appointment time to begin their dental care. If the wait time goes beyond this period, an

explanation for the delay should be given to the Member and/or Member’s representative,

with

the option to reschedule the appointment.

Main Dental Home Responsibilities

Texas defines a Main Dental Home as the dental provider who supports an ongoing relationship

with the member that includes all aspects of oral health care delivered in a comprehensive,

continuously accessible, coordinated, and family‐centered way. Establishment of a member’s

Main Dental Home, begins no later than 6 months of age and includes referrals to dental

specialists when appropriate.

The Dental Contractor must develop a network of Main Dental Home Providers, consisting of

Federally Qualified Health Centers and individuals who are general dentists and pediatric

dentists, who will provide preventative care and refer Members for specialty care as needed.

In accordance with standards of practice and policy guidelines set forth by the American

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Academy of Pediatric Dentistry, Main Dental Home Providers must perform a caries risk

assessment as part of the comprehensive oral examination. Main Dental Home Providers must

bill one of the following caries risk assessment codes: D0601, D0602, or D0603 with every

comprehensive oral examination (D0150), oral examination for a patient under 3 years of age

(D0145), or periodic dental evaluation (D0120). These risk codes will be included as part of an

informational component of the D0150, D0145 or D0120 billing code and do not have a separate

rate attached to them. Claim will reject when any of the following codes D0150, D0145 or D0120

are submitted without a caries risk assessment code. Providers will be given the standard 120-

day appeal period for the denied claim to submit proof of performing a caries risk assessment.

The TMPPM and the MMC‐CHIP Dental Provider Manual is effective with this change as of

October 1, 2015.

First Dental Home Initiative Responsibilities

In addition to establishing a Network of Main Dental Home Providers, the Dental Contractor

must implement a “First Dental Home Initiative” for Medicaid Members. This initiative will

enhance dental providers’ ability to assist Members and their primary caregivers in obtaining

optimum oral health care through First Dental Home visits. The First Dental Home visit can be

initiated as early as 6 months of age and must include the following:

• Comprehensive oral examination;

• Oral hygiene instruction with primary caregiver;

• Dental prophylaxis, if appropriate;

• Topical fluoride varnish application when teeth are present;

• Caries risk assessment; and

• Dental anticipatory guidance as defined in the Texas Medicaid Provider Procedures

Manual (TMPPM), Volume 2, Children's Services Handbook and requires documentation

of the specific information conveyed to the parent/guardian for at least 3 of the 8

anticipatory guidance topics found in the handbook.

Medicaid Members from 6 through 35 months of age may be seen for dental checkups by a

certified First Dental Home Initiative provider as frequently as every sixty (60) days if Medically

Necessary.

Only certified, participating First Dental Home Providers may bill a D0145 for a first dental home

oral evaluation. The member is only allowed one of D0120 or D0150 in a six month period.

D1330, D1206, and D1208 will be denied when billed on the same date of service as D0145.

Providers must be certified to be a Texas Health Steps Dentist. If you are a dentist and wish to be

certified to bill Medicaid for First Dental Home Services, you must complete the following

requirements:

• Complete this First Dental Home training and download the Continuing Education (CE)

certificate.

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• Submit a First Dental Home Certification Application, Form 1091 (fillable PDF) to be

certified as a First Dental Home provider.

The completed application form and CE certificate should be emailed to:

[email protected].

Alternatively, the completed form and CE certificate can be faxed to 512-483-3979.

Updates to Contact Information

DentaQuest publishes a provider directory to Members. The directory is updated periodically and

includes: provider name, practice name (if applicable), office addresses(s), telephone number(s),

provider specialty, panel status (for example, providers limiting their practice to existing

Members only), office hours, and any other panel limitations that DentaQuest is aware

of, such

as patient age minimum and maximum, etc. The online provider directory reflects the

most

current information.

It is very important that you notify DentaQuest of any change in your practice information.

Please complete the Provider Change Form, fax it to DentaQuest at 262.241.4077 or call us at

1‐800‐896‐2374 to report any changes. Please also contact TMHP to update your Medicaid

enrollment profile.

Plan Termination

Provider shall render to Members all Covered Services and continue to provide Covered

Services

to Members. After the date of termination from participation, upon the request of DentaQuest,

Provider shall continue to provide Covered Services to Members for a period not to exceed

ninety (90) days during which time payment will be made pursuant to the

DentaQuest Provider

Contract.

Please refer to the DentaQuest TX Provider Contract for more information regarding

termination.

Referral to Specialists Process

Referrals to Specialists

Main Dental Home Providers must assess the dental needs of Members for referral

to specialty care providers and provide referrals as needed. Main Dental Home

Providers must coordinate Member’s care with specialty care providers after

referral.

Routine preventative care referrals must be provided within 30 days of request.

Texas Medicaid and CHIP Dental Services Members do not require authorization to

see a dental specialist. However, only services provided by a Contracting Dentist are

covered by DentaQuest, therefore a Texas Medicaid or CHIP Dental Services

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Member must be treated by a dentist enrolled in the Texas Medicaid or

CHIP Dental

Services. In the event it is necessary to refer a Member to a specialist for treatment,

please be sure to refer the Member to a contracted

Texas Medicaid or CHIP Dental

Services dentist. You may look at the DentaQuest website to locate a dental

specialist in the area.

Members with Special Health Care Needs may have direct access to Specialists as

appropriate for the Member’s condition and identified needs.

If you cannot locate a specialist in your area, you may call DentaQuest’s Provider

Call Center’s toll‐free telephone number at 1‐800‐896‐2374 to facilitate a Member

referral to a Specialist.

Referrals from a Main Dentist to General Dentist/Pedodontist for Interim Care Also

known as the “Texas Interim Care Transfer (ICT) Process”

This process is to be utilized when a Main Dentist Dental Home Provider (Main

Dentist) determines that it is necessary for another Main Dentist (general or

pediatric dentist) to provide interim care to a Member; yet the Main Dentist

assignment should be maintained. The Interim Care Transfer Form will need to be

filled out only if other Main Dentist is at a location different than Main Dentist

Dental Home Provider.

A. Main Dentist identifies the need for interim care for a Member.

B. Main Dentist completes the Interim Care Transfer Form (which is available

via the web portal and in A‐23) with the interim Transfer Provider’s (general

or pediatric dentist) information and the need for the Member to have

services rendered outside the Main Dental Home. Transfer Provider must be

in network for claims to be paid.

C. Main Dentist completes the Interim Care Transfer on the portal

(provideraccess.dentaquest.com).

D. The approval is valid for 270 days. Both Main Dental Home Provider and

Transfer Provider may review the status of the submitted Interim Care

Transfer on the portal.

E. Transfer Provider renders services within 270 days (otherwise an extension is

required) and submits claim.

F. DentaQuest processes the claim and pays the Transfer Provider.

G. As the Main Dentist, any follow‐up and coordination of care is the

responsibility of the Main Dentist initiating the Interim Care Transfer.

Verify Member Eligibility and/or Authorizations for Service

Member Eligibility

Participating Providers may access Member eligibility information through DentaQuest’s

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Interactive Voice Response (IVR) system or through the Provider Web Portal (located in the

“Providers Only” section of DentaQuest’s website at www.dentaquest.com.) The eligibility

information received from either system will be the same information you would receive by

calling DentaQuest’s Customer Service department; however, by utilizing either system you can

get information 24 hours a day, 7 days a week without having to wait for an available Customer

Service Representative. A provider must verify Member eligibility and/or authorizations for

service.

If you are having difficulty accessing either the IVR or the Provider Web Portal, please contact

the

Customer Service department at 1‐800‐896‐2374. They will be able to assist you in utilizing

either system.

Access to eligibility information via the Provider Web Portal

DentaQuest’s Provider Web Portal currently allows Providers to verify a Member’s eligibility as

well as submit claims directly to DentaQuest. You can verify the Member’s eligibility on‐line by

entering the Member’s date of birth, the date of service and the Member’s identification number

or last name and first initial. To access the eligibility information via DentaQuest’s

website,

simply log on to the website at www.dentaquest.com. Once you have entered the

website, click

on “Dentist”. From there choose your ‘State” and press go. You will then be able to log in using

your password and ID. First time users will have to register by utilizing TIN and State. If you have

not received instruction on how to complete Provider Self Registration, you can access the guide

at http://www.dentaquest.com/getattachment/State-Plans/Regions/texas/Dentists-Page/New-

Provider-Registration-Tip-Sheet.pdf. If you need further assistance, please contact DentaQuest’s

Customer Service Department at 1‐800‐896‐2374.

Once logged in, select patient from the portal menus then choose Member eligibility search.

You

are able to check on an unlimited number of Members and can print off the summary of

eligibility given by the system for your records. Be sure to verify eligibility on the date of service.

Directions for using DentaQuest’s IVR to verify eligibility:

Entering system with Tax and Location ID’s

1. Call DentaQuest Customer Service at 1-800-896-2374.

2. After the greeting, stay on the line for English or press 1 for Spanish.

3. Enter or state your NPI number.

4. Enter or state your last 4 digits of your Tax ID.

5. The system will read back the NPI entered. If correct, press (1); if it needs to be re-entered, press (2).

6. Enter Member ID – contains only numbers, press (1) or say “number”; contains numbers and letters,

press (2) or say “letter”.

7. Enter Member DOB.

8. The system will read back the DOB entered. If correct, press (1); if it needs to be re-entered, press (2).

9. Multiple options will be given –press the option number that corresponds to the reason for the call.

10. Upon system verification of the Member’s eligibility, you will be prompted to repeat the information

given, verify the eligibility of another Member, get benefit in formation, get limited claim history on this

Member, or get fax confirmation of this call.

11. If you choose to verify the eligibility of an additional Member(s), you will be asked to repeat step 5

above for each Member.

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Access to eligibility information via the IVR line

To access the IVR, simply call DentaQuest’s Customer Service department at 1‐800‐896‐2374

and

press 2 for eligibility. The IVR system will be able to answer all of your eligibility questions for as

many Members as you wish to check. Once you have completed your eligibility checks,

you will

have the option to check benefit history and/or transfer to a Customer Service

Representative to

answer any additional questions. Using your telephone keypad, you can request eligibility

information on a Medicaid or CHIP Member by entering the Member’s

recipient identification

number and a date of service. If the system is unable to verify the

Member information you

entered, you will be transferred to a Customer Service

Representative.

If eligibility is verified, the dentist may not treat the Member as a private‐pay patient to avoid

Texas Medicaid or CHIP Dental Services billing, obtaining prior authorization (when necessary)

complying with any other program requirement. In addition, upon obtaining eligibility

verification, the dentist cannot bill the Texas Medicaid Dental Services Member for any covered

service.

Once eligibility verification has been established, a dentist can decline to treat a Member only

under the following circumstances:

• The dentist is unable to provide the particular service(s) that the Member requires.

• The Member is not eligible for dental services.

• The Member is unable to present satisfactory identification.

A dentist who declines to accept a Member must do so before accessing eligibility information

except in the above circumstances. If the dentist is unwilling to accept an individual as a patient,

the dentist has no authority to access the individual’s confidential eligibility

information.

Please note that due to possible eligibility status changes, the information provided by either

system does not guarantee payment. Eligibility is determined by HHSC or its designee(s). The

eligibility information provided by DentaQuest to contracting offices reflects the eligibility

information received. The Medicaid Member will be covered until his/her name no longer

appears on the eligibility information provided to DentaQuest. Therefore, it is vital that

providers verify eligibility before initiating treatment to a patient.

Authorizations of Service

Authorizations are utilization tools that require Participating Providers to submit

“documentation” associated with certain dental services for a Member. Participating Providers

will not be paid if this “documentation” is not provided to DentaQuest. Participating Providers

must hold the Member, DentaQuest, and HHSC harmless as set forth in the Provider

Participation Agreement if coverage is denied for failure to submit documentation for review

after the service is rendered. Authorization can be made through prior approval or by

prepayment review. Approved authorizations expire after 180 days and Orthodontic

authorizations expire after 3 years. Prior authorization is optional for all covered procedures with

the

exception of all Orthodontic codes (see Review Requirements identified in Exhibits A and B).

Non-urgent specialty care should be provided within 60 Days of authorization.

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Providers must note that "PA Not Required" is not equivalent to "Medically Necessary". It is not

to be assumed that payment will be dispensed for a service that does not require Prior

Authorization. Approval of prior authorization does not guarantee payment. The service will still

be subject to retrospective review to confirm medical necessity.

DentaQuest utilizes specific dental utilization criteria as well as an authorization process to

manage utilization of services. DentaQuest’s operational focus is to assure compliance with its

utilization criteria. The criteria are included in this manual. Please review these criteria as well as

the benefits covered (Exhibit A and B) to understand the decision making process used to

determine payment for services rendered.

A. Prior Authorization‐ Dental services or treatment locations that require review

by DentaQuest for determination of medical necessity and approval before

delivery are subject to prior authorization. Proper documentation must be

submitted with requests for prior authorization.

B. Pre‐Payment Review‐ Dental procedures that require review by DentaQuest

for determination of medical necessity prior to reimbursement for the

procedures. These procedures can be administered before determination of

medical necessity is rendered but require submission of proper documentation

for approval to process the claim.

Your submission of “documentation” should include:

1) Radiographs, narrative, or other information where requested (see

Exhibits A and B for specifics by code).

2) CDT codes on the ADA claim form.

Your submission should be sent on a 2018, 2019, or later ADA approved claim form. The tables of

Covered Services (Exhibits A and B) contain a column marked “Review Required.” A “Yes” in this

column indicates that the service listed requires that documentation be submitted with the

claim

for pre‐payment review in order to be considered for reimbursement. The “Documentation

Required” column will describe what information is necessary for pre‐payment

review.

Submitting Authorization or Claims with X‐Rays

• Electronic submission using the web portal

• Electronic submission using National Electronic Attachment (NEA) is recommended.

For more information, please visit www.nea‐fast.com and click the “Learn More”

button. To register, click the “Provider Registration” button in the middle of the home

page.

• Submission of duplicate radiographs (which we will recycle and not return)

• Submission of original radiographs with a self‐addressed stamped envelope (SASE) so

that we may return the original radiographs. Note that determinations will be sent

separately and any radiographs received without a SASE will not be returned to the

sender.

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Please note we also require radiographs be mounted when there are 4 or more radiographs

submitted at one time. If four (4) or more radiographs are submitted and not mounted, they

will

be returned to you and your request for prior authorization and/or claims will not be

processed.

You will need to resubmit a copy of the 2018, 2019, or newer ADA form that was originally

submitted, along with mounted radiographs so that we may process the claim correctly.

Acceptable methods of mounted radiographs are:

• Radiographs duplicated and displayed in proper order on a piece of duplicating

film.

• Radiographs mounted in a radiograph holder or mount designed for this

purpose.

Unacceptable methods of mounted radiographs are:

• Cut out radiographs taped or stapled together.

• Cut out radiographs placed in a coin envelope.

• Multiple radiographs placed in the same slot of a radiograph holder or

mount.

All radiographs, must be of good diagnostic quality, include member’s full name, date films

taken, and identify the patients left and right side

It is important not to submit original x‐rays especially if they are the only diagnostic record for

your patient. Duplicate films and x‐ray copies of diagnostic quality, including paper copies of

digitized images are acceptable. DentaQuest does not generally return x‐rays and other

supporting documentation. However, if you wish to have your x‐rays returned, they must be

submitted with a self‐addressed stamped envelope.

Electronic Attachments

FastAttach™ DentaQuest accepts dental radiographs electronically via FastAttach™ for

authorization requests and claims submissions. DentaQuest, in conjunction with National

Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers the opportunity to

submit all claims electronically, even those that require attachments. This program allows

transmissions via secure Internet lines for radiographs, periodontic charts, intraoral pictures,

narratives and EOBs.

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or

damaged attachments and accelerates claims and prior authorization processing. It is compatible

with most claims clearinghouses or practice management systems.

For more information or to sign up for FastAttach go to https://fastattachweb.nea-fast.com/ or

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call NEA at

1‐800‐782‐5150.

OrthoCAD™ DentaQuest accepts orthodontic models electronically via OrthoCAD™ for

authorization requests. Submissions using OrthoCAD™ also require the submission of the form

found on page B‐5. DentaQuest allows Enrolled Participating Providers the opportunity to submit

all orthodontic models electronically. This program allows transmissions via secure

Internet lines

for orthodontic models. OrthoCAD™ is inexpensive and easy to use, reduces

administrative costs,

eliminates lost or damaged models and accelerates claims and prior authorization processing. It

is compatible with most claims clearinghouse or practice

management systems.

For more information or to sign up for OrthoCAD™ go to www.cadentinc.com or call OrthoCAD™

at 1‐800‐577‐8767.

Continuity of Care

Subject to compliance with applicable federal and state laws and professional standards

regarding the confidentiality of dental records, participating dentists must assist DentaQuest in

achieving continuity of care for Texas Medicaid and CHIP Dental Services Members through the

maximum sharing of Members’ dental records. Within thirty (30) days of a written request by a

Texas Medicaid or CHIP Dental Services Member, you must be able to provide copies of the

patient’s dental records to any other dentist treating such Member.

Texas Medicaid and CHIP Dental Services Members are not subject to limitations or exclusions of

covered dental benefits due to a pre‐existing condition.

Dental Records

Organization

1. The record must have areas for documentation of the following information:

a. Registration data including a complete health history.

b. Medical alert predominantly displayed inside chart jacket.

c. Initial examination data.

d. Radiographs.

e. Periodontal and Occlusal status.

f. Treatment plan/Alternative treatment plan.

g. Progress notes to include diagnosis, preventive services, treatment

rendered, and medical/dental consultations.

h. Miscellaneous items (correspondence, referrals, and clinical laboratory

reports).

2. The design of the record must provide the capability or periodic update, without

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the loss of documentation of the previous status, of the following information.

a. Health history.

b. Medical alert.

c. Examination/Recall data.

d. Periodontal status.

e. Treatment plan.

3. The design of the record must ensure that all permanent components of the

record are attached or secured within the record.

4. The design of the record must ensure that all components must be readily

identified to the patient, (i.e., patient name, and identification number on each

page).

5. The organization of the record system must require that individual records be

assigned to each patient.

Content ‐ The patient record must contain the following:

1. Adequate documentation of registration information which requires entry of

these items:

a. Patient’s first and last name.

b. Date of birth.

c. Sex.

d. Address.

e. Telephone number.

f. Name and telephone number of the person to contact in case of

emergency.

2. Adequate health history that requires documentation of these items:

a. Current medical treatment.

b. Significant past illnesses.

c. Current medications.

d. Drug allergies.

e. Hematologic disorders.

f. Cardiovascular disorders.

g. Respiratory disorders.

h. Endocrine disorders.

i. Communicable diseases.

j. Neurologic disorders.

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k. Signature and date by patient.

l. Signature and date by reviewing dentist.

m. History of alcohol and/or tobacco usage including smokeless tobacco.

3. Adequate update of health history at subsequent recall examinations which

requires documentation of these items:

a. Significant changes in health status.

b. Current medical treatment.

c. Current medications.

d. Dental problems/concerns.

e. Signature and date by reviewing dentist.

4. A conspicuously placed medical alert inside the chart jacket that documents highly

significant terms from health history. These items are:

a. Health problems which contraindicate certain types of dental treatment.

b. Health problems that require precautions or pre‐medication prior to

dental treatment.

c. Current medications that may contraindicate the use of certain types of

drugs or dental treatment.

d. Drug sensitivities.

e. Infectious diseases that may endanger personnel or other Members.

5. Adequate documentation of the initial clinical examination which is dated and

requires descriptions of findings in these items:

a. Blood pressure. (Recommended)

b. Head/neck examination.

c. Soft tissue examination.

d. Periodontal assessment.

e. Occlusal classification.

f. Dentition charting.

6. Adequate documentation of the patient’s status at subsequent Periodic/Recall

examinations which is dated and requires descriptions of changes/new findings in

these items:

a. Blood pressure. (Recommended)

b. Head/neck examination.

c. Soft tissue examination.

d. Periodontal assessment.

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e. Dentition charting.

7. Radiographs which are:

a. Identified by patient name.

b. Dated.

c. Designated by patient’s left and right side.

d. Mounted (if intraoral films).

8. Indication of the patient’s clinical problems/diagnosis.

9. Adequate documentation of the treatment plan (including any alternate

treatment options) that specifically describes all the services planned for the

patient by entry of these items:

a. Procedure.

b. Localization (area of mouth, tooth number, surface).

10. Adequate documentation of the periodontal status, if necessary, which is dated

and requires charting of the location and severity of these items:

a. Periodontal pocket depth.

b. Furcation involvement.

c. Mobility.

d. Recession.

e. Adequacy of attached gingiva.

f. Missing teeth.

11. Adequate documentation of the patient’s oral hygiene status and preventive

efforts which requires entry of these items:

a. Gingival status.

b. Amount of plaque.

c. Amount of calculus.

d. Education provided to the patient.

e. Patient receptiveness/compliance.

f. Recall interval.

g. Date.

12. Adequate documentation of medical and dental consultations within and outside

the practice which requires entry of these items:

a. Provider to whom consultation is directed.

b. Information/services requested.

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c. Consultant’s response.

13. Adequate documentation of treatment rendered which requires entry of these

items:

a. Date of service/procedure.

b. Description of service, procedure and observation. Documentation in

treatment record must contain documentation to support the level of

American Dental Association Current Dental Terminology code billed as

detailed in the nomenclature and descriptors. Documentation must be

written on a tooth by tooth basis for a per tooth code, on a quadrant basis

for a quadrant code, and on a per arch basis for an arch code.

c. Type and dosage of anesthetics and medications given or prescribed.

d. Localization of procedure/observation. (tooth #, surface, quadrant etc.)

e. Signature of the Provider who rendered the service.

14. Adequate documentation of the specialty care performed by another dentist that

includes:

a. Patient examination.

b. Treatment plan.

c. Treatment status.

Compliance

1. The patient record has one explicitly defined format that is currently in use.

2. There is consistent use of each component of the patient record by all staff.

3. The components of the record that are required for complete documentation of

each patient’s status and care are present.

4. Entries in the records are legible.

5. Entries of symbols and abbreviations in the records are uniform, easily interpreted

and are commonly understood in the practice.

Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare provider, your office is required to comply with all aspects of the HIPAA

regulations that have gone/will go into effect as indicated in the final publications of the various

rules covered by HIPAA.

DentaQuest has implemented various operational policies and procedures to ensure that it is

compliant with the Privacy Standards as well. DentaQuest also intends to comply with all

Administrative Simplification and Security Standards by their compliance dates. One aspect of

our compliance plan will be working cooperatively with our providers to comply with the HIPAA

regulations. In relation to the Privacy Standards, DentaQuest has/will be modifying its provider

contracts to reflect the appropriate HIPAA compliance language. The contractual updates include

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the following in regard to record handling and HIPAA requirements:

• Maintenance of adequate dental/medical, financial and administrative records

to covered dental services rendered by Provider in accordance with federal

and state

law.

• Safeguarding of all information about Members according to applicable state and

federal laws and regulations. All material and information, in particular information

relating to Members or potential Members, which is provided to or obtained by or

through a Provider, whether verbal, written, tape, or otherwise, shall be reported as

confidential information to the extent confidential treatment is provided under state

and federal laws.

• Neither DentaQuest nor Provider shall share confidential information with a

Member’s employer absent the Member’s consent for such disclosure.

• Provider agrees to comply with the requirements of the Health Insurance Portability

and Accountability Act (“HIPAA”) relating to the exchange of information and shall

cooperate with DentaQuest in its efforts to ensure compliance with the privacy

regulations promulgated under HIPAA and other related privacy laws.

Provider and DentaQuest agree to conduct their respective activities in accordance with the

applicable provisions of HIPAA and such implementing regulations.

In relation to the Administrative Simplification Standards, you will note that the benefit tables

included in this ORM reflect the most current coding standards (CDT 2009‐2010) recognized by

the ADA. Effective the date of this manual, DentaQuest will require providers to submit all claims

with the proper CDT 2009‐2010 codes listed in this manual. In addition, all paper claims

must be

submitted on a 2018, 2019, or later approved ADA claim form.

Note: Copies of DentaQuest’s HIPAA policies are available upon request by contacting

DentaQuest’s Customer Service department at 1‐800‐896‐2374

Access to Second Opinion

DentaQuest may request a clinical evaluation by a regional dental consultant who conducts

clinical examinations, prepares objective reports of dental conditions and evaluates treatment

that is proposed or has been provided for the purpose of providing DentaQuest with a second

opinion.

A second opinion may be required prior to treatment when necessary to make a benefit

determination. Authorization for second opinions after treatment can be made if a Member has

a complaint regarding the quality of care provided. The Member and the treating dentist will be

notified when a second opinion is necessary and appropriate. When a second opinion is

authorized through a regional dental consultant, all charges will be paid by DentaQuest.

Members may otherwise obtain a second opinion about treatment from any contracting dentist

they choose, and claims for the examination or consultation may be submitted for payment.

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Such claims will be paid in accordance with the benefits of the program.

Justification Regarding Out‐of‐Network Referrals

Out of network referrals are covered only if:

• The service is medically necessary and the covered service is not available through an in‐

network provider.

• The existing (in‐network) provider requests that the work be done by an OON provider

(referral).

• Reimbursement for Medicaid OON providers is 95% of the fee‐for‐service rate in effect

on the date‐of‐service unless a different reimbursement amount is agreed upon.

Please contact Provider Services for assistance in locating an in‐network provider.

Informed Consent for Utilization of Papoose Boards

Written and informed consent from a legal guardian must be obtained and documented in the

patient record prior to protective stabilization. The patient’s record must include:

• Informed consent (should occur on a day separate from the treatment, if possible)

• Type of stabilization used

• Indication for stabilization

• Behavior during stabilization

• Any untoward outcomes, i.e. skin markings

• The duration of the application

Indications*

• A previously cooperative patient quickly becomes uncooperative during the

appointment

in order to protect the patient’s safety and expedite completion of the

treatment

Contradictions**

• Patient’s with a history of psychological trauma due to restraint (unless no other

alternatives are available)

A parent has the right to terminate restraint at any time. If termination is requested, the

practitioner should complete the necessary steps to bring the procedure to a safe conclusion

before ending the appointment.

Goals of Behavior Management

• Establish communication.

• Alleviate fear and anxiety.

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• Deliver quality dental care.

• Build a trusting relationship between dentist and child.

• Promote the child’s positive attitude towards oral/dental health.

Routine use of restraining devices to stabilize young children in order to complete their dental

care is not acceptable practice, violates the standard of care and will result in termination of the

provider from the network.

Dentists must not restrain children without formal training in protective stabilization.

General Dentists should consider referring to dental specialists those Members who they

consider to be candidates for protective stabilization.

Dental auxiliaries must not use restraining devices to stabilize children.

1. Routine use of restraining devices to stabilize young children in order to complete

their dental care is not acceptable practice, violates the standard of care, and will

result in termination of the provider from the network.

2. Dentists must not restrain children without formal training in protective stabilization.

3. General dentists should consider referring to dental specialists those Members who

they consider to be candidates for protective stabilization.

4. Dental auxiliaries must not use restraining devices to immobilize children.

*American Academy of Pediatric Dentistry. Guideline on behavior management.

Reference

Manual 2002‐2003.

2013 AAPD Clinical Guidelines on Protective Stabilization for Pediatric Dental Patients

**Tennessee Board of Dentistry Newsletter. Spring 2004

Routine, Therapeutic/Diagnostic, and Urgent Care Dental Services

Definitions

• Routine dental services include diagnostic and preventive visits.

• Therapeutic services are those such as fillings, crowns, root canals and/or extractions.

• Emergency dental services are limited to the following:

• Procedures necessary to control bleeding, relieve pain, and eliminate acute

infection.

• Operative procedures required to prevent imminent loss of teeth.

• Treatment of injuries to the teeth and supporting structures.

Routine restorative procedures and root canal therapy are not emergency services.

Emergency

services must be justified with documentation. The dentist’s narrative

documentation should

describe the nature of the emergency, including relevant clinical information about the patient’s

condition and stating why the emergency services rendered

were considered to be immediately

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necessary.

EMERGENCY Treatments and Authorizations

If a patient presents with an emergency condition that requires immediate treatment or

intervention, you should always take necessary clinical steps to mitigate pain, swelling,

or other symptoms that might put the members overall health at risk and completely

document your findings. After treatment, please complete the appropriate authorization

request, and enter EMERGENCY/ URGENT in box 35, and the appropriate narrative or descriptor

of the patient’s conditions, including all supporting documentation.

Please FAX this to 262-241-7150.

DentaQuest will process emergency authorization requests as high priority. After you receive the

authorization number, then and only then should you submit the claim. Our system will link the

authorization number and the claim, and payment should be processed.

Requirements for Scheduling of Appointments

DentaQuest Dentists are expected to meet minimum standards with regards to appointment

availability. Dental appointments are to be made during normal business hours and within a

reasonable time from the date of the Member’s request. Appointment Standards are:

• Preventive – 14 calendar days.

• Therapeutic/diagnostic‐ 14 calendar days.

• Urgent‐ 24 hours.

Coordination of Non‐Capitated Services

Medicaid Services Not Covered by DentaQuest

The following Texas Medicaid programs and services are paid for by HHSC’s claims administrator

instead of DentaQuest. Medicaid Members can get these services from Texas Medicaid

providers.

1. Early Childhood Intervention (ECI) case management/service coordination;

2. DSHS case management for Children and Pregnant Women;

3. Texas School Health and Related Services (SHARS); and

Either the Member’s medical plan or HHSC’s claims administrator will pay for treatment and

devices for craniofacial anomalies, and for emergency dental services that a Member gets in a

hospital or ambulatory surgical center. This includes hospital, physician, and related medical

services (e.g., anesthesia and drugs) for:

• Treatment of a dislocated jaw, traumatic damage to teeth, and removal of cysts;

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• Treatment of oral abscess of tooth or gum origin; and

• Treatment of craniofacial anomalies.

Nonemergency medical transportation (NEMT) services may be used to access Covered Dental

Services provided by the Dental Contractor. NEMT Services are coordinated by the member’s

Medicaid medical plan.

If a Member is in need of assistance in coordinating any non‐capitated services, a Member

Advocate may be contacted to assist. Please contact our Member or Provider Service Line and

ask to be referred to a Member Advocate.

MEDICAL TRANSPORTATION PROGRAM (MTP)

What is MTP?

MTP is a state administered program that provides Non‐Emergency Medical Transportation

(NEMT) services statewide for eligible Medicaid members who have no other means of

transportation to attend their covered healthcare appointments. MTP can help with rides to the

doctor, dentist, hospital, drug store, and any other place you get Medicaid services.

What services are offered by MTP?

• Passes or tickets for transportation such as mass transit within and between cities or

states, to include rail, bus, or commercial air

• Curb to curb service provided by taxi, wheelchair van, and other transportation vehicles

• Mileage reimbursement for a registered individual transportation participant (ITP) or a

covered healthcare event. The ITP can be the responsible party, family member, friend,

neighbor, or member.

• Meals and lodging allowance when treatment requires an overnight stay outside the

county of residence

• Attendant services (a responsible adult who accompanies a minor or an attendant

needed for mobility assistance or due to medical necessity, who accompanies the

member to a healthcare service)

• Advanced funds to cover authorized transportation services prior to travel

Call MTP:

For more information about services offered by MTP, members, advocates and providers can call

the toll free line at 1‐877‐633‐8747. In order to be transferred to the appropriate transportation

provider, members are asked to have either their Medicaid ID# or zip code available at the time

of the call.

CHIP Services Not Covered by DentaQuest

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Some services are paid by CHIP medical plans instead of DentaQuest. These services include

treatment and devices for craniofacial anomalies, and emergency dental services that a Member

gets in a hospital or ambulatory surgical center. This includes hospital, physician, and related

medical services (e.g., anesthesia and drugs) for:

• Treatment of a dislocated jaw, traumatic damage to teeth, and removal of cysts;

• Treatment of oral abscess of tooth or gum origin; and

• Treatment of craniofacial anomalies.

If a Member is in need of assistance in coordinating any non‐capitated services, a Member

Advocate may be contacted to assist. Please contact our Member or Provider Service Line and

ask to be referred to a Member Advocate.

Effective January 1, 2019 - Retro eligibility Recoupment Process

Funds will be recouped from paid claims with dates of service on or after January 1, 2019 where the

member’s eligibility has been retro-actively terminated. All decisions with regards to payment are subject

to appeal. You may appeal our handling of payment by submitting a written request for review to HHSC.

Provider Appeal Process to HHSC (related to claim recoupment due to Member

disenrollment)

Provider may appeal claim recoupment by submitting the following information to HHSC:

• A letter indicating that the appeal is related to a managed care disenrollment/recoupment and

that the provider is requesting an Exception Request.

• The Explanation of Benefits (EOB) showing the original payment. Note: This is also used when

issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare

Partnership (TMHP) to grant an authorization for the exact items that were approved by the

plan.

• The EOB showing the recoupment and/or the plan's "demand" letter for recoupment. If

sending the demand letter, it must identify the member name, identification number, DOS, and

recoupment amount. The information should match the payment EOB.

• Completed clean claim. All paper claims must include both the valid NPI and TPI number. Note:

In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted

with the authorization number and the provider will need to submit a corrected claim that

contains the valid authorization number.

Mail appeal requests to:

Texas Health and Human Services Commission HHSC Claims Administrator Contract Management

Mail Code-91X P.O. Box 204077

Austin, Texas 78720-4077

E. Medicaid Dental Services Provider Complaint and Appeal

Process

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Medicaid Provider Complaints

Procedures governing the provider complaints process are designed to identify and resolve

provider complaints in a timely and satisfactory manner. Complaints must be resolved within

thirty (30) calendar days. If a complaint cannot be resolved within thirty (30) days, the provider

will be notified in writing the status of the complaint. The submitted documentation must specify

the relevant subject (i.e. Appeal/Complaint). All documentation regarding an appeal/complaint

must be submitted for processing. Submission copies must be retained for the provider's record.

Complaints to DentaQuest may be submitted using the following methods:

(Non‐claim related) • By telephone at 1‐800‐896‐2374

(Claim related) • In writing to:

DentaQuest‐ TX Dental Services

Complaints & Grievances

P.O. Box 2906 Milwaukee,

WI 53201‐2906

If a provider is not satisfied after completing the DentaQuest Complaint Process or feels that

they did not receive due process, providers may file a complaint with HHSC. A provider must

exhaust the DentaQuest Complaint Process before filing with HHSC.

Medicaid complaint requests may be mailed to the following address:

Texas Health and Human Services Commission

Provider Complaints

Health Plan Operations, H‐320

PO Box 85200

Austin, Texas 78708

Or e‐mail complaint requests to: [email protected]

Medicaid Provider Appeals

For appealed claims, Providers must submit all appeals of denied claims and requests for

adjustments on paid claims within one hundred and twenty (120) days from the date of

disposition of the Explanation of Benefits (EOB) on which that claim appeared. The submitted

documentation must specify the relevant subject (i.e. Appeal/Complaint). All documentation

regarding an appeal/complaint must be submitted for processing. Submission copies must be

retained for the provider's record. Appeals should be mailed to:

DentaQuest TX HHSC Dental Services

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Complaints & Grievances - Appeals

P.O. Box 2906 Milwaukee,

WI 53201‐2906

We will respond to the appeal within thirty (30) calendar days after we receive the request with

any necessary supporting documentation.

Peer to Peer Reviews

If you have a question or concern regarding any determination, you may speak with a dental

director during regular business hours, by calling the Provider Services line at 1‐800‐896‐2374.

Clinical review guidelines used in all determinations will be provided in writing, upon request.

F. Medicaid Dental Services Member Complaint and Appeal

Process

Medicaid Member Complaint

The Member receives the following information as it pertains to Medicaid Member Complaints:

A Medicaid Member Complaint is an expression of dissatisfaction expressed by a Member,

orally

or in writing to DentaQuest, about any matter other than an Action. As provided by 42 C.F.R.

§438.400, possible subjects for Complaints include, but are not limited to, the quality of care of

services provided, and aspects of interpersonal relationships such as rudeness of a provider or

employee, or failure to respect the Medicaid Member’s rights.

What should I do if I have a complaint?

We want to help. If you have a complaint, please call us toll‐free at 1‐800‐516‐0165 to tell us

about your problem. A DentaQuest Member Advocate can help you file a complaint. Just call 1‐

800‐516‐0165. Most of the time, we can help you right away or at the most within a few days.

You can also send your complaint in writing to:

DentaQuest‐ TX HHSC Dental Services

Complaints & Grievances

P.O. Box 2906 Milwaukee,

WI 53201‐2906

Once we receive your complaint, DentaQuest will acknowledge your complaint within five (5)

business days of receipt. We will respond within thirty (30) calendar days of receipt of your

complaint.

The resolution letter will:

1. Explain the resolution of the complaint.

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2. State the specific dental and contractual reasons for the resolution.

3. State the specialization of any dentist or other Provider consulted.

4. Include a complete description of the process for appeal, including the

deadlines for

the appeals process and the deadlines for the final decision on the appeal.

If the Member is not satisfied with the outcome, who else can they call?

Once you have gone through the DentaQuest complaint process, you can complain to the

Health

and Human Services Commission (HHSC) by calling toll‐free 1‐866‐566‐8989, 8 A.M. – 5P.M.,

Monday - Friday. If you have a hearing disability, call the toll-free Relay Texas service at 7-1-1 or

1-800-735-2389. If you would like to make your complaint in writing, please send it to the

following address:

Mail: Texas Health and Human Services Commission

Ombudsman for Managed Care

P.O. Box 13247

Austin, TX 78711-3247

Fax: 888-780-8099

If you can get on the Internet, you can access more information here:

Online: https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman/hhs-ombudsman-

managed-care-help

MDCP/DBMD ESCALATION HELP LINE

What is the MDCP/DBMD Escalation Help Line?

The MDMDCP/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 escalation help line can help solve issues related to the STAR Kids managed care program.

Help can include answering questions about Medicaid fair hearings and continuing services while

appealing.

When should I call the 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 they will work to connect you with the

right people.

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

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No. The MDCP/DBMD escalation help line is part of the Medicaid program. The Ombudsman

offers an independent review of concerns and can be reached at 866-566-8989 or go on the

Internet (hhs.texas.gov/managed-care-help). 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 help line?

The escalation line is available Monday through Friday from 8 a.m.–8 p.m. After these hours,

please leave a message and one of our trained on-call staff will call you back.

Can I call any time?

The escalation line is available Monday through Friday from 8 a.m.-8 p.m. After these hours,

please leave a message and one of our trained on-call staff will call you back.

Medicaid Member Appeals

The Member receives the following information as it pertains to Medicaid Member Appeals:

A Medicaid Member Appeal is the formal process by which a Member or his or her

representative requests a review of DentaQuest’s Action.

If a Member, or Member’s representative, disagrees with a decision made to deny a covered

service, they have the right to appeal. To do this, the appeal must be made within sixty (60) days

from the date of receipt of the notice of action. DentaQuest will acknowledge the receipt

of the

appeal within five (5) business days and complete the appeal within thirty (30) days.

What can I do if DentaQuest denies or limits my Member’s request for a covered service?

You, with the Member’s consent, can ask for an appeal in writing, or you can call and ask

DentaQuest for an appeal. We will send you and the Member a one‐page appeal form that you,

the Member, or someone else representing the Member can fill out and return to us. Every oral

Appeal received must be confirmed by a written, signed Appeal by the Member or his or her

representative, unless an Expedited Appeal is requested.

How will I find out if services are denied?

We will send you a Provider Determination Letter and the Member will receive a Notice of Action

Letter.

Timeframes for the Appeal Process

DentaQuest must complete the entire standard Appeal process within 30 days after receipt of

the initial written or oral request for Appeal.

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You or DentaQuest can ask for an extension of up to fourteen (14) Days if there is a need for

more information in order to make a decision in the best interest of the Member.

DentaQuest

will send you a written notice explaining the reason for the delay.

When does the Member have the right to ask for an appeal?

The Member has the right to request an appeal if he/she is not satisfied or disagrees with the

action. An appeal is the process by which you and/or the Member request a review of the

action.

The Member has the right to request an appeal for denial of payment for service in whole or in

part.

To ensure continuation of currently authorized services, the Member must file the appeal on or

before the later of: ten (10) Days following DentaQuest’s mailing of the notice of the

action or

the intended effective date of the proposed action. The Member may be required to pay the cost

of services furnished while the appeal is pending, if the final decision is adverse to the Member.

Appeals must be accepted orally or in writing.

Can someone from DentaQuest help a Member file an appeal?

Yes. However,

• Member’s option to request an External Medical Review and State Fair Hearing must be no

later than 120 Days after DentaQuest mails the appeal decision notice.

• Member’s option to request only a State Fair Hearing must be no later than 120 Days after

DentaQuest mails the appeal decision notice.

A DentaQuest Member Advocate can help the Member file an appeal. Just call 1‐800‐516‐ 0165.

Medicaid Member Expedited Appeals

The Member receives the following information as it pertains to Medicaid Member Expedited

Appeals:

How to Request an Emergency Appeal

If you have an emergency appeal, you can call us at 1‐800‐516‐0165. Call and tell us you need

expedited appeal. A request for an expedited appeal can be made orally or in writing.

Timeframes for Emergency Appeals

We will respond within three (3) business days from the day we receive your request for appeal.

What happens if DentaQuest denies the request for an Emergency Appeal?

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If DentaQuest does not think the appeal is life‐threatening, the Member will be notified the

same

day that the decision is made. The appeal will still be worked on, but the decision may

take up to

thirty (30) days.

Who can help me file an Emergency Appeal?

If you need help filing an expedited appeal, call us toll‐free at 1‐800‐516‐0165, and a DentaQuest

Member Advocate will help you.

State Fair Hearing Information

Can a Member ask for a State Fair Hearing?

If a member, as a member of DentaQuest, disagrees with DentaQuest’s decision, the member

has the right to ask for a State Fair Hearing. The Member may name someone to represent him

or her by writing a letter to DentaQuest telling them the name of the person you want

representing you. A provider may be your representative. You or your representative must ask

for the State Fair Hearing within one‐hundred and twenty (120) days of the date on the

DentaQuest letter that tells of the decision you are challenging. 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 Program

Attn: Fair Hearing Coordinator

P.O. Box 2906 Milwaukee,

WI 53201‐2906

Or call: 1‐800‐516‐0165

If you ask for a State Fair Hearing within 10 Days from the time the hearing notice is received

from DentaQuest, you have the right to keep getting any service DentaQuest 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 the hearing notice is received, the service DentaQuest denied will be

stopped.

If you or your representative requests a State Fair Hearing, you will get a packet of information

with 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 the Member a final decision within 90 Days from the date you

asked for the

hearing.

External Medical Review Information

Can a Member ask for an External Medical Review?

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If a Member, as a member of the dental plan, disagrees with the dental plan’s decision, the

Member has the right to ask for an External Medical Review. An External Medical Review is an

optional, extra step the Member can take to get the case reviewed for free before the State Fair

Hearing. The Member may name someone to represent him or her by writing a letter to the

dental plan telling the Dental Contractor the name of the person the Member wants to represent

him or her. A provider may be the Member’s representative. The Member or the Member’s

representative must ask for the External Medical Review within 120 days of the date the dental

plan mails the letter with the internal appeal decision. If the Member does not ask for the

External Medical Review within 120 days, the Member may lose his or her right to an External

Medical Review. To ask for an External Medical Review, the Member or the Member’s

representative should either:

• Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an

attachment to the Member Notice of Dental Contractor Internal Appeal Decision letter and mail

or fax it to DentaQuest by using the address or fax number at the top of the form.

• Cal DentaQuest at 1‐800‐516‐0165

• Email DentaQuest at [email protected]

If the Member asks for an External Medical Review within 10 days from the time the Member

gets the appeal decision from the dental plan, the Member has the right to keep getting any

service the dental plan denied, at least until the final State Fair Hearing decision is made. If the

Member does not request an External Medical Review within 10 days from the time the Member

gets the appeal decision from the dental plan, the service the dental plan denied will be stopped.

The Member may withdraw the Member’s request for an External Medical Review before it is

assigned to an Independent Review Organization or while the Independent Review Organization

is reviewing the Member’s External Medical Review request. An External Medical Review cannot

be withdrawn if an Independent Review Organization has already completed the review and

made a decision.

Once the External Medical Review decision is received, the Member has the right to withdraw

the State Fair Hearing request. If the Member continues with the State Fair Hearing, the Member

can also request the Independent Review Organization be present at the State Fair Hearing. The

Member can make both of these requests by contacting the Dental Contractor at

[email protected] or the HHSC Intake Team at [email protected].

Can a Member ask for an emergency External Medical Review?

If a Member believes that waiting for a standard External Medical Review will seriously

jeopardize the Member’s life or health, or the Member’s ability to attain, maintain, or regain

maximum function, the Member or Member’s representative may ask for an emergency External

Medical Review and emergency State Fair Hearing by writing or calling DentaQuest. To qualify for

an emergency External Medical Review and emergency State Fair Hearing review through HHSC,

the Member must first complete DentaQuest’s internal appeals process.

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G. CHIP Provider Complaints and Appeals

CHIP Provider Complaints

Procedures governing the provider complaints process are designed to identify and resolve

provider complaints in a timely and satisfactory manner. Complaints must be resolved within

thirty (30) calendar days. If a complaint cannot be resolved within thirty (30) days, the provider

will be notified in writing the status of the complaint.

The submitted documentation must specify the relevant subject (i.e. Appeal/Complaint). All

documentation regarding an appeal/complaint must be submitted for processing. Submission

copies must be retained for the provider's record.

Complaints to DentaQuest may be submitted using the following methods:

(Non‐claim related) • By telephone at 1‐800‐896‐2374

(Claim related) • In writing to:

DentaQuest‐ TX Dental Services

Complaints & Grievance

P.O. Box 2906 Milwaukee,

WI 53201‐2906

If a provider is not satisfied after completing the DentaQuest Complaint Process or feels that

they did not receive due process, providers may file a complaint with the Texas Department of

Insurance. A provider must exhaust the DentaQuest Complaint Process before filing with TDI.

CHIP complaint requests may be mailed to the following address:

Office Address

Mailing Address

1601 Congress Avenue

Austin, TX 78701

PO Box 12030

Austin, TX 78711-2030

Or e‐mail complaint requests to: HPM [email protected]

CHIP Provider Appeals

For appealed claims, Providers must submit all appeals of denied claims and requests for

adjustments on paid claims within one hundred and twenty (120) days from the date of

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disposition of the Explanation of Benefits (EOB) on which that claim appeared.

The submitted documentation must specify the relevant subject (i.e. Appeal/Complaint). All

documentation regarding an appeal/complaint must be submitted for processing. Submission

copies must be retained for the provider's record.

Appeals should be mailed to:

DentaQuest TX HHSC Dental Services

Complaints & Grievances - Appeals

P.O. Box 2906 Milwaukee,

WI 53201‐2906

We will respond to the appeal within thirty (30) calendar days after we receive the request with

any necessary supporting documentation.

Peer to Peer Reviews

If you have a question or concern regarding any determination, you may speak with a dental

director during regular business hours, by calling the Provider Services line at 1‐800‐896‐2374.

Clinical review guidelines used in all determinations will be provided in writing, upon request.

“Like Specialty” Peer to Peer Reviews

Like Specialty Peer‐to‐Peer Process: DentaQuest’s internal process where the Provider

disagrees

with DentaQuest’s claim appeal’s decision based on Medical Necessity and requests a “like

specialty” Peer‐to‐Peer discussion with a Dental Director. The Dental Director resolving the

dispute must hold the same specialty or a related specialty as the appealing Provider and is not

the Dental Director that was involved in any previous determinations. The Dental Director

completing the “like specialty” peer to peer discussions is a non‐network provider.

Procedure

Requesting a “like specialty” Peer‐to‐Peer discussion

1. Upon completion of an appeal relating to claims payment, if the appealing Provider

disagrees with the appeal decision; they have the right to request a “like specialty”

peer‐to‐peer discussion with a Specialist within 30 days from the

appeal disposition

of an adverse determination. This process applies only when:

a. The services in question have already been rendered;

b. The Provider dispute is related to denial on the basis of Medical Necessity;

and

c. The Provider has completed the appeal process and received the

appeal

determination.

2. Peer‐to‐Peer like‐specialty meeting requests can be submitted verbally or in

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writing. The Provider may contact DentaQuest’s Provider Call Center’s toll free

number at 800.896.2374 or may submit a written request to DentaQuest’s

Complaints & Appeals Department at the following address:

DentaQuest‐ TX HHSC Dental Services

Peer Review Request

P.O. Box 2906 Milwaukee,

WI 53201‐2906

3. Peer‐to‐Peer requests are handled by the Complaint and Appeals Specialist (C&G

Specialist) and the resolution coordinated with Dental Directors and other areas

within DentaQuest. Non‐participating Consultants of a similar specialty as the

Provider will be contracted by DentaQuest to resolve claim disputes related to

denial on the basis of Medical Necessity that remain unresolved subsequent to a

provider appeal.

4. Upon the receipt of the Peer‐to‐Peer request, the Complaints and Grievance

Specialist contacts the Provider within five (5) days from the receipt. The provider

will be contacted via email or phone, based on the provider’s

preference.

5. The C&G Specialists will schedule a conference between the Provider and the

Consultant within two weeks, or as soon as the Provider and Consultant’s schedules

permit.

6. The C&G Specialist will provide all records related to the case to the Consultant in

advance to the scheduled conference. DentaQuest’s Clinical Guidelines which

incorporates the guidelines from: American Dental Association, the American

Pediatric Dental Association, the Medicaid Program and any contract specific

related items will be included. These guidelines are used as a reference and taken

into consideration for each individual case. These guidelines are available upon

request.

Resolution of “like‐specialty” peer‐to‐peer discussion

1. Upon completion of the like‐specialty peer‐to‐peer conference, the Consultant will

communicate the decision via fax or e‐mail to the C&G Specialist.

2. The C&G Specialists will document the Consultant’s decision and relevant

information in the C&G Module.

3. The Consultant’s decision is binding on DentaQuest and the Provider.

4. A resolution to the Provider will be rendered and written communication is sent to

the Provider within two business days from completion of the like‐specialty

discussion.

CHIP Member Complaints and Appeals

CHIP Member Complaint

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The Member receives the following information as it pertains to CHIP Member Complaints:

A CHIP Member Complaint is any dissatisfaction, expressed by a Complainant, orally or in writing,

to DentaQuest, with any aspect of DentaQuest’s operation, including, but not limited to,

dissatisfaction with plan administration, procedures related to review or appeal of an Adverse

Determination, as defined in Texas Insurance Code, Chapter 843, Subchapter G; the

denial,

reduction, or termination of a service for reasons not related to Medical Necessity; and the way a

service is provided. The term does not include misinformation that is resolved

promptly by

supplying the appropriate information or clearing up the misunderstanding to the

satisfaction of

the CHIP Member.

What should I do if I have a complaint?

We want to help. If you have a complaint, please call us toll‐free at 1‐800‐508‐6775 to tell us

about your problem. A DentaQuest Member Services Advocate can help you file a complaint.

You can also send your complaint in writing to:

DentaQuest‐ TX HHSC Dental Services

Complaints & Grievance

P.O. Box 2906 Milwaukee,

WI 53201‐2906

Who do I call?

Just call 1‐800‐508‐6775. Most of the time, we can help you right away or at the most within a

few days.

Can someone from DentaQuest help a Member file a complaint?

Yes. A DentaQuest Member Advocate can help the Member file a complaint. Just call 1‐800‐ 508‐

6775.

How long will it take to investigate and resolve my complaint?

Once we receive your complaint, DentaQuest will acknowledge your complaint within five (5)

business days of receipt. We will respond within thirty (30) calendar days of receipt of your

complaint.

The resolution letter will:

1. Explain the resolution of the complaint.

2. State the specific dental and contractual reasons for the resolution.

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3. State the specialization of any dentist or other Provider consulted.

4. Include a complete description of the process for appeal, including the deadlines for the

appeals process and the deadlines for the final decision on the appeal.

If I am not satisfied with the outcome, who else can I call?

Any Member, including a Member who has attempted to resolve a complaint through the

complaint process described above, may file a complaint with the Texas Department of

Insurance:

Office Address

Mailing Address

1601 Congress Avenue

Austin, TX 78701

PO Box 12030

Austin, TX 78711-2030

The Department’s toll‐free telephone number is 1‐800‐252‐3439.

The commissioner will investigate a complaint against us to determine our compliance with the

insurance laws within sixty (60) days after the Department receives the complaint and all

information necessary for the Department to determine compliance. The commissioner may

extend the time necessary to complete an investigation in the event any of the following

circumstances occur:

a. Additional information is needed.

b. An on‐site review is necessary.

c. We, the Provider, or the complainant do not provide all documentation

necessary to complete the investigation.

d. Other circumstances beyond the control of the Department occur.

We will not engage in any retaliatory action (including termination or refusal to renew a

Contract) against a Member or a dentist (on behalf of a Member) for filing a complaint or

appealing a decision.

CHIP Member Appeal

The Member receives the following information as it pertains to CHIP Member Appeals:

A CHIP Member Appeal is the formal process by which DentaQuest addresses Adverse

Determinations.

What can I do if DentaQuest denies or limits my patient’s request for a covered service?

You, with the Member’s consent, can ask for an appeal in writing, or you can call and ask

DentaQuest for an appeal. We will send you and the Member a one‐page appeal form that you,

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the Member, or someone else representing the Member can fill out and return to us.

How will I find out if the appeal is denied?

We will send a written resolution of the appeal within thirty (30) calendar days after receipt of an

appeal. Investigation and resolution of appeals involving ongoing Emergency Dental Services

will

be concluded in accordance with the dental immediacy of the case, but no later than 24

hours

after receipt of request for appeal. At the request of the Member, we will provide,

instead of an

appeal panel, a Provider who has not previously reviewed the case and who is of the same or

similar specialty as ordinarily manages the procedure or treatment under appeal.

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The Provider reviewing the appeal may interview the Member or the Member’s designated

representative and will make a decision on the appeal. Initial notice of decision of the appeal

may be delivered orally, but will be followed by a written notice of the determination within

three days.

Notice of our final decision will include a statement of the specific clinical and/or Contract

provision(s) on which the decision was based, and the toll‐free telephone number and address

for MAXIMUS.

Timeframes for the Appeal Process

Non‐emergency appeals will be processed within thirty (30) calendar days from the day we

receive it.

You or DentaQuest can ask for an extension of up to fourteen (14) calendar days if there is a

need for more information in order to make a decision. DentaQuest will send you a written

notice explaining the reason for the delay.

When does a Member have the right to request an appeal?

In the event a Member is not satisfied with our resolution of a complaint, other than issues

relating to a Member’s annual maximum or eligibility information provided to DentaQuest by

Texas HHSC or its designee, he/she will have the right to appeal the decision. A Member also has

the right to appeal any adverse decision including denial of payment for services in whole or in

part. A Member may be required to pay the cost of services furnished while the appeal is

pending if the final decision is adverse to the Member.

A Member may call DentaQuest to request an appeal. Within five (5) business days after the

Member calls, we will send them an appeal form. We must receive the Member’s completed,

signed appeal form to confirm their appeal request, unless an expedited appeal is requested.

Every oral appeal received must be confirmed by a written, signed appeal by the Member or his

or her representative, unless an expedited appeal is requested. (If the appeal request is related

to a dental emergency, we do not need a completed, signed form to process the appeal.)

After we receive the written request for an appeal, we will send the Member a letter within five

(5) business days. The letter will explain the Member’s right to:

• Submit a written appeal to an appeal panel or appear before an appeal panel in person.

• Present information to help the Member’s.

• Ask questions about the decision we made regarding the complaint.

No later than five (5) business days before the appeal panel meets, we will send the Member:

• Copies of any documents that the appeal panel will review.

• The specialty field of any dentists who helped us review your case.

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• Information about the Members of the appeal panel.

We may tell you the outcome of your appeal right away. We will always send you a written

letter

of the decision within three (3) business days.

The letter will include:

• Our decision about your appeal.

• The reasons for our decision.

• Contact information for MAXIMUS.

Appeals must be accepted orally or in writing.

Can someone from DentaQuest help the Member file an appeal?

Please have the Member call our Member Call Center toll‐free at 1‐800‐508‐6775 for help in

filing an appeal.

CHIP Member Expedited Appeals

The Member receives the following information as it pertains to CHIP Member Expedited

Appeals:

How to Request an Expedited Appeal

If you have an emergency appeal, you can call us at 1‐800‐516‐0165. Call and tell us you need

expedited appeal. A request for an expedited appeal can be made orally or in writing.

Timeframes for Expedited Appeals

We will respond within three (3) business days from the day we receive your request for appeal.

What happens if DentaQuest denies the request for an Expedited Appeal?

If DentaQuest does not think the appeal is life‐threatening, the Member will be notified the

same

day that the decision is made. The appeal will still be worked on, but the decision may

take up to

thirty (30) days.

Who can help me file an Expedited Appeal?

If you need help filing an expedited appeal, call us toll‐free at 1‐800‐516‐0165, and a DentaQuest

Member Advocate will help you.

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Independent Review Organization (IRO) for External CHIP Appeal Reviews

What is an Independent Review Organization?

The purpose of an Independent Review Organization (IRO) is to provide an independent review

of health care services that are denied by certain entities, on the basis that the services are not

medically necessary or appropriate, or are experimental, or investigational. These entities

include Utilization Review Agents, Health Maintenance Organizations, Insurance Carriers, and

Certified Workers' Compensation Networks.

How do I request a review by an Independent Review Organization?

If a CHIP Member, a representative designated by a Member, or their Dentist has sent an appeal

request to DentaQuest and it was denied, they may be able to have their request for medically

necessary services evaluated by DentaQuest’s contracted IRO, MAXIMUS, as part of an External

Review. This evaluation is processed by MAXIMUS at no cost to the Member.

MAXIMUS must receive the completed HHS‐Administered Federal External Review Request Form

within four months of the date that DentaQuest sent you a final decision denying your services

or your claim for payment. You will be asked to describe the dental services that were denied by

DentaQuest and state the reason that you believe DentaQuest’s decision was not correct.

HHS‐Administered Federal External Review Request Form

HHS-Administered Federal External Review Request Form

HHS Federal External Review Process Appointment of Representative Form

Appointment of Representative Form

MAXIMUS Federal Services will use the information you provide on this form to get the relevant

information and documents from DentaQuest. You may add supporting information and

documents you think DentaQuest may not be able to provide.

For example, you may choose to provide MAXIMUS with:

• Documents to support the claim, such as dentist’s letters, reports, bills,

medical records, and Explanation of Benefits (EOB) forms

• Letters you sent to DentaQuest about the claim

• Letters that DentaQuest sent to you about the claim

You do not have to give MAXIMUS this additional information. However, if you do not provide

any additional information, MAXIMUS Federal Services may decide your case based only on the

information DentaQuest gives us.

You can give MAXIMUS additional information for your external review by sending it with this

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form in the below options.

Mail to: HHS Federal External Review Request, MAXIMUS

Federal Services,

3750 Monroe Avenue, Suite 705,

Pittsford, NY 14534.

Fax to: 1-888-866-6190

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

How long will it take to investigate and resolve my external appeal?

DentaQuest will immediately be contacted by MAXIMUS after receiving the request for an

External Review. DentaQuest will give MAXIMUS all documents and information used to make

the internal appeal decision within five (5) business days.

Standard External Review requests:

The Member or Member’s representative will receive written notice of the final External Review

decision no later than 45 days after MAXIMUS receives the request for an External Review or as

soon as the review has been completed.

Expedited Independent Review Organization request

In most cases, Members, their representative, or Dentist must complete any mandatory appeals

or opportunities for reconsideration offered by DentaQuest before MAXIMUS can do an external

review. In urgent situations, MAXIMUS may be able to do a review even if the Member,

Member’s designated representative, or Dentist have not made all appeals and reconsiderations.

If you believe your situation is urgent, you may ask for an expedited (fast) review. An urgent care

situation is one in which the Member’s health may be in serious jeopardy or, the Member may

have pain that cannot be controlled while awaiting the external review decision.

To ask for an expedited external review:

Submit an online request at https://externalappeal.com

OR Fax this form to 1-888-866-6190

OR Mail this form to:

HHS Federal External Review Request,

MAXIMUS Federal Services,

3750 Monroe Avenue, Suite 705,

Pittsford, NY 14534.

In urgent care situations, MAXIMUS Federal Services will accept a request for external review

from a medical professional who knows about the Member’s condition. The medical professional

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will not be required to submit proof of authorization.

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

How long will it take to investigate and resolve my expedited external appeal?

For an expedited External Review request:

MAXIMUS will give DentaQuest and the Member or Member’s representative the External

Review decision no later than within 72 hours of receiving the request.

MAXIMUS will contact the Member or Member’s representative by phone and will also send a

written version of the decision within 48 hours of that phone call. DentaQuest must take action

on the notice if the ruling is in favor of the Member, and provide authorization, or coordinate the

services after receiving the External Review decision notice. DentaQuest is bound to comply with

the decision of the External Review.

HHSC Oversight

HHSC reserves the right and retains the authority to make reasonable inquiry and to conduct

investigations into Provider and Texas CHIP Dental Services Member complaints. The dentist

must cooperate in all such HHSC inquiries/investigations.

H. Medicaid Member Eligibility and Added Benefits

Eligibility

The Texas HHSC Medicaid Dental Programs provide dental coverage for children enrolled.

Eligibility is determined by the HHSC.

Verifying Eligibility

To verify Member eligibility providers may contact:

https://www.yourtexasbenefits.com/

*This site is only to verify Member eligibility, not Main Dental Home assignment.

If Members have questions regarding enrolling in the program or their loss of eligibility, they

should be referred to the Enrollment Broker at 1‐800‐964‐2777.

Main Dental Home Verification

Main Dental Home assignment must be verified on the DentaQuest Provider Web Portal (located

in the “Providers Only” section of DentaQuest’s website at www.dentaquest.com. You may also

contact DentaQuest’s Customer Service Department at 1‐800‐896‐2374 to verify

Main Dental

Home assignment.

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DentaQuest Member Identification Card

Members will receive a DentaQuest TX Medicaid ID Card. Participating Providers are

responsible

for verifying that Members are eligible at the time services are rendered and to determine if

Members have other health insurance.

Please note that due to possible eligibility status changes, this information does not guarantee

payment and is subject to change without notice.

Sample of the DentaQuest USA Medicaid Dental Program ID card:

DentaQuest recommends that each dental office make a photocopy of the Member’s

identification card each time treatment is provided. It is important to note that the

identification

card is not dated, and it does not need to be returned should a Member lose eligibility.

Therefore, an identification card in itself does not guarantee that a person is

currently enrolled

in the Texas Medicaid Dental Program.

DentaQuest recommends that providers verify Main Dental Home assignment on the Provider

Web Portal prior to treatment, as the Member’s assignment may have changed, or the

Member may be using an old card.

Call DentaQuest

Participating Providers may access Member eligibility information through DentaQuest’s

Interactive Voice Response (IVR) system or through the Provider Web Portal (“Providers Only”

section of DentaQuest’s website at www.dentaquest.com.

To access the IVR, simply call DentaQuest’s Customer Service department at 1‐800‐896‐2374

and

press 2 for eligibility. The IVR system will be able to answer all of your eligibility questions for as

many Members as you wish to check.

Automated Inquiry System line/TXMedConnect

This is a provider line responsible for assisting with issues not addressed by other available

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provider lines. The Contact Center Representative provides general information concerning the

Texas Medicaid Program. The Contact Center is open from 7 a.m. to 7 p.m. Central Time and can

be reached at the number listed below:

TMHP Contact Center/Automated Inquiry System (AIS)

1‐800‐925‐9126 or 512‐335‐5986

www.tmhp.com

Automatic Re‐enrollment

If a Member loses Medicaid eligibility and then regains eligibility within six (6) months, the

Member is automatically reassigned his previous plan. The Member may choose to switch plans,

please see Medicaid Plan Changes below.

Disenrollment

Can DentaQuest ask that my child get dropped from their dental plan?

DentaQuest can ask that a child be removed from their plan for the following reasons:

• The child or the child’s caregiver misuses the child’s Membership card or

loans it

to another person,

• The child or the child’s caregiver is disruptive, unruly, or uncooperative at the

dentist’s office, or

• The child or the child’s caregiver refuses to follow the dental plan’s rules and

restrictions.

Neither DentaQuest nor a provider m ay request a disenrollment based on an adverse change in

the Member’s health or the utilization of services which are medically necessary for the

treatment of a Member’s condition. A provider cannot take retaliatory action against a Member.

Medicaid Plan Changes

You can change your child’s dental plan to another by contacting the Medicaid Enrollment

Broker’s toll‐free telephone number at 1‐800‐647‐6558. During the first 90 Days after you are

enrolled in a dental plan, you can change to another plan for any reason. After 90 Days, with a

dental plan, you can change to another plan once for any reason. If you show good cause, you

can also change dental plans at any time. An example of good cause is that you can’t get the

care

that you need through the dental plan.

If you call to change dental plans on or before the 15th of the month, the change will take place

on the first day of the next month. If you call after the 15th of the month, the change will take

place the first day of the second month after that. For example:

• If you ask to change plans on or before April 15, the change will take place on May 1.

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• If you ask to change plans after April 15, the change will take place on June 1.

Medicaid Added Benefits

Medicaid Member Value Added Services

Free Dental Care Kit for Child and Parent

Get off to the right start by receiving a preventative dental service within 180 days of when you sign up

with us. When you do, you can get one zippered backpack and a dental kit that includes a toothbrush,

a tube of toothpaste and a brushing chart and stickers. We will also include a spinning toothbrush, a

timer and floss for the parent. That way, you can brush along with your child! One reward per eligible

member, per lifetime.

Walmart Gift Card for Preventive Visit

You can also get a $25 OTC Network Rewards gift card when your child gets a qualifying Texas Health

Steps dental checkup. OTC Network is the gift card vendor. The OTC Network rewards gift card allows

you to buy eligible products with your rewards card at thousands of participating stores. You can use

the OTC Rewards gift card to buy items such as healthy foods, baby care items and over the counter

health products. For a full list of eligible items and participating retailers, visit

SpeakBenefits.com/Dental. One gift card per eligible member, per lifetime.

Additional value‐added services:

Members 6 months – 6 years

There is treatment that can fix some cavities with no

drilling. This treatment is not normally covered under

the Medicaid & CHIP programs. If your dentist says you

need it to protect you from cavities, you can get it at no

cost. Must be prescribed by Main Dentist.

Other limitations may apply, please discuss with your

Main Dentist.

Members who have follow-up

care with their Main Dentist after

visiting the ER for dental care.

Eligible Members may receive one $10 OTC Network

rewards gift card for taking the following steps if they

have had to visit a hospital emergency room for dental

care.

• Have a follow-up visit with their Main Dentist

within 30 days of visiting the emergency room

for a dental related issue.

• Complete the quiz and submit to DentaQuest.

Redemption form & quiz is available on pages

40 and 41 of the Member Handbook, the secure

Member Website at

MemberAccess.DentaQuest.com and online at

www.DentaQuest.com/TXMember.

Here’s what you need to do to get your $25 OTC Network Rewards gift card and/or dental kit:

1. Fill out your information on the Extra Benefits redemption form.

2. You can make copies of the Extra Benefits redemption form if you need more than one.

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3. Mail the signed form to DentaQuest. You can use the postage-paid envelope included with this

Member Handbook: DentaQuest

P.O. Box 2906

Milwaukee, WI 53201-2906

If you have questions on the Extra Benefits, call DentaQuest customer service at 1-800-508-6775.

You can also visit us online at www.DentaQuest.com/TXMember.

I. CHIP Member Eligibility and Added Benefits

Eligibility

The Texas HHSC CHIP Dental Programs provide dental coverage for twelve (12) continuous

months for children enrolled.

Verifying Eligibility

Providers may contact: https://www.yourtexasbenefits.com/

Eligibility is determined by the HHSC. CHIP Children who enroll in Texas CHIP Dental Services

receive twelve (12) months of continuous coverage. Families must re‐enroll their children every

twelve (12) months.

*This site is only to verify Member eligibility, not Main Dental Home assignment.

If Members have questions regarding enrolling in the program or their loss of eligibility, they

should be referred to the Enrollment Broker at 1‐800‐964‐2777.

Main Dental Home Verification

Main Dental Home assignment must be verified on the DentaQuest Provider Web Portal (located

in the “Providers Only” section of DentaQuest’s website at www.dentaquest.com). You may also

contact DentaQuest’s Customer Service Department at 1‐800‐896‐2374 to verify

Main Dental

Home assignment.

DentaQuest CHIP Identification Card

Members will receive a DentaQuest TX CHIP ID Card. Participating Providers are responsible for

verifying that Members are eligible at the time services are rendered and to determine if

Members have other health insurance.

Please note that due to possible eligibility status changes, this information does not guarantee

payment and is subject to change without notice.

Sample of the DentaQuest USA CHIP Dental Program ID card:

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DentaQuest recommends that each dental office make a photocopy of the Member’s

identification card each time treatment is provided. It is important to note that the

identification

card is not dated and it does not need to be returned should a Member lose eligibility. Therefore,

an identification card in itself does not guarantee that a person is

currently enrolled in the

Texas CHIP Dental Program.

DentaQuest recommends that providers verify Main Dental Home assignment on the Provider

Web Portal prior to treatment, as the Member’s assignment may have changed or the Member

may be using an old card.

Re‐enrollment

Families must re‐enroll their children in the CHIP Dental Program every twelve (12) months.

Disenrollment

Can DentaQuest ask that my child get dropped from their dental plan?

DentaQuest can ask that a child be removed from their plan for the following reasons:

• The child or the child’s caregiver misuses the child’s Membership card or loans

it to another person.

• The child or the child’s caregiver is disruptive, unruly, or uncooperative at the

dentist’s office.

• The child or the child’s caregiver refuses to follow the dental plan’s rules and

restrictions.

Neither DentaQuest nor a provider may request a disenrollment based on an adverse change in

the Member’s health or the utilization of services which are medically necessary for the

treatment of a Member’s condition.

A provider cannot take retaliatory action against a Member.

CHIP Plan Changes

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

If the child has been in a CHIP dental plan less than 90 days, they can change dental plans. Call

CHIP toll‐free at 1‐800‐647‐6558.

Members are allowed to make plan changes under the following circumstances:

• For any reason within 90 Days of enrollment in CHIP;

• For cause at any time; and

• During the annual re‐enrollment period.

The Member’s child cannot change dental plans after being in the plan ninety (90) days unless

their child is granted an exception for a “good cause.” The Member also cannot change dental

plans if their child has reached his or her annual dental benefit limit. HHSC will make the final

decision.

CHIP Added Benefits

CHIP Member Value Added Services

Free Dental Care Kit for Child and Parent

Get off to the right start by receiving a preventative dental service within 180 days of when you sign up

with us. When you do, you can get one zippered backpack and a dental kit that includes a toothbrush,

a tube of toothpaste and a brushing chart and stickers. We will also include a spinning toothbrush, a

timer and floss for the parent. That way, you can brush along with your child! One reward per eligible

member, per lifetime.

Walmart Gift Card for Preventive Visit

You can also get a $25 OTC Network Rewards gift card when your child gets a qualifying Texas Health

Steps dental checkup. OTC Network is the gift card vendor. The OTC Network rewards gift card allows

you to buy eligible products with your rewards card at thousands of participating stores. You can use

the OTC Rewards gift card to buy items such as healthy foods, baby care items and over the counter

health products. For a full list of eligible items and participating retailers, visit

SpeakBenefits.com/Dental. One gift card per eligible member, per lifetime.

Additional value‐added services:

Members

6 months – 6 years

There is treatment that can fix some cavities with no drilling.

This treatment is not normally covered under the Medicaid &

CHIP programs. If your dentist says you need it to protect you

from cavities, you can get it at no cost. Must be prescribed by

Main Dentist.

Other limitations may apply, please discuss with your

Main Dentist.

Members who have follow-up care

with their Main Dentist after

visiting the ER for dental care.

Eligible Members may receive one $10 OTC Network rewards

gift card for taking the following steps if they have had to visit a

hospital emergency room for dental care.

• Have a follow-up visit with their Main Dentist within

30 days of visiting the emergency room for a dental

related issue.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

• Complete the quiz and submit to DentaQuest.

Redemption form & quiz is available on pages 37, 38

and 41 of the Member Handbook, the secure

Member Website at MemberAccess.DentaQuest.com

and online at www.DentaQuest.com/TXMember.

* One dental care kit per eligible member, per lifetime.

Here’s what you need to do to get your $25 OTC Network Rewards gift card and/or dental kit:

1. Fill out your information on the Extra Benefits redemption form.

2. You can make copies of the Extra Benefits redemption form if you need more than one.

3. Mail the signed form to DentaQuest. You can use the postage-paid envelope included with

the Member Handbook:

DentaQuest

P.O. Box 2906

Milwaukee, WI 53201-2906

If you have questions on the Extra Benefits, call DentaQuest customer service at 1-800-508-6775.

You can also visit us online at www.DentaQuest.com/TXMember.

Member Rights and Responsibilities

**The Member receives the following information as it pertains to Member Rights and

Responsibilities:

CHILDREN’S MEDICAID DENTAL SERVICES MEMBER RIGHTS AND RESPONSIBILITES

MEMBER RIGHTS

1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That

includes the right to:

a. Be treated fairly and with respect.

b. Know that your dental records and discussions with your dentists will be kept

private and confidential.

2. You have the right to a reasonable opportunity to choose a dental plan and dentist. You

have the right to change to another plan or dentist in a reasonably easy manner. That

includes the right to:

a. Be told how to choose and change your dental plan and dentist.

b. Choose any dental plan you want that is available in their area and choose your

dentist from that plan.

c. Change your dentist.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

d. Change your dental plan without penalty.

e. Be told how to change your dental plan or your dentist.

3. You have the right to ask questions and get answers about anything that you do not

understand. That includes the right to:

a. Have your dentist explain your dental care needs to you and talk to the dentist

about the different ways your dental care problems can be treated.

b. Be told why care or services were denied and not given.

4. You have the right to agree to or refuse treatment and actively participate in treatment

decisions. That includes the right to:

a. Work as part of a team with your dentist in deciding what dental care is best for

you.

b. Say yes or no to the care recommended by your dentist.

5. You have the right to use each available complaint and appeal process through

DentaQuest and through Medicaid, and get a timely response to complaints, appeals,

External Medical Reviews and State Fair Hearings. That includes the right to:

a. Make a complaint to DentaQuest or to the state Medicaid program about your

dental care, your dentist or your dental plan.

b. MDCP/DBMD escalation help line for Members receiving Waiver services via the

Medically Dependent Children Program or Deaf/Blind Multi-Disability Program

c. Get a timely answer to your complaint.

d. Use DentaQuest’s appeal process and be told how to use it.

e. Ask for an External Medical Review and State Fair Hearing from the state Medicaid

program and get information about how that process works.

f. Ask for a State Fair Hearing without an External Medical Review from the state

Medicaid and receive information about how that process works.

6. You have the right to timely access to care that does not have any communication or

physical access barriers. That includes the right to:

a. Have telephone access to a dental professional 24 hours a day, 7 days a week to

get any emergency or urgent care that you need.

b. Get dental care in a timely manner.

c. Be able to get in and out of a dental care provider’s office. This includes barrier‐

free access for people with disabilities or other conditions that limit mobility, in

accordance with the Americans with Disabilities Act.

d. Have interpreters, if needed, during appointments with your dentist and when

talking to your dental plan. Interpreters include people who can speak in your

native language, help someone with a disability, or help you understand the

information.

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DentaQuest USA Insurance Company, Inc February 1, 2024

e. Be given information you can understand about DentaQuest plan rules, including

the dental care services that you can get and how to get them.

7. You have the right to not be restrained or secluded when it is for someone else’s

convenience, or is meant to force you to do something that you do not want to do, or is

to punish you.

8. You have a right to know that dentists, hospitals, and others who care for you can advise

you about your health status, dental care, and treatment. Before any medically necessary

dental services and treatment begin, the services and treatment must be fully explained

to you and you must give permission in writing (informed consent). DentaQuest cannot

prevent

the dentists, hospitals, and others who care for you from giving you this

information,

even if the care or treatment is not a covered service.

9. You have a right to know that you are not responsible for paying for covered services.

Dentists, hospitals, and others cannot require you to pay copayments or any other

amounts for covered services.

Medicaid Member Responsibilities

1. You must learn and understand each right you have under the Medicaid program. That

includes the responsibility to:

a. Learn and understand your rights under the Medicaid program.

b. Ask questions if you do not understand your rights.

c. Learn what choices of dental plans are available in your area.

2. You must abide by DentaQuest’s and Medicaid’s policies and procedures. That includes

the responsibility to:

a. Learn and follow DentaQuest’s rules and Medicaid rules.

b. Choose your dental plan and a dentist quickly.

c. Make any changes in your dental plan and dentist in the ways established by

Medicaid and by DentaQuest.

d. Keep your scheduled appointments.

e. Cancel appointments in advance when you cannot keep them.

f. Always contact your dentist first for your non‐emergency dental needs.

g. Be sure that you have approval from your dentist before going to a specialist.

h. Understand when you should and should not go to the emergency room.

3. You must share information about your health with your dentist and learn about service

and treatment options. That includes the responsibility to:

a. Tell your dentist about your health.

b. Talk to your dentist about your dental care needs and ask questions about the

different ways your dental care problems can be treated.

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DentaQuest USA Insurance Company, Inc February 1, 2024

c. Help your dentist get your dental records.

4. You must be involved in decisions relating to service and treatment options, make

personal choices, and take action to maintain your health. That includes the

responsibility to:

a. Work as a team with your provider in deciding what dental care is best for you.

b. Understand how the things that you do can affect your dental health.

c. Do the best that you can to stay healthy.

d. Treat dentists and staff with respect.

Additional Member Responsibilities while using NEMT Services

1. When requesting NEMT Services, you must provide the information requested by the

person arranging or verifying your transportation.

2. You must follow all rules and regulations affecting your NEMT services.

3. You must return unused advanced funds. You must provide proof that you kept your dental

appointment prior to receiving future advanced funds.

4. You must not verbally, sexually, or physically abuse or harass anyone while requesting or

receiving NEMT services.

5. You must not lose bus tickets or tokens and must return any bus tickets or tokens that you

do not use. You must use the bus tickets o tokens only to go to your dental appointment.

6. You must only use NEMT Services to travel to and from your dental appointments.

7. If you have arranged for an NEMT service but something changes, and you no longer need

the service, you must contact the person who helped you arrange your transportation as

soon as possible.

CHIP DENTAL SERVICES MEMBER RIGHTS AND RESPONSIBILITIES

CHIP Member Rights

1. You have a right to get accurate, easy‐to‐understand information to help you make good

choices about your dentists and other providers.

2. You have a right to know how your dentists are paid. You have a right to know about

what those payments are and how they work.

3. You have a right to know how DentaQuest decides whether a service is covered and/or

medically necessary. You have the right to know about the people at DentaQuest who

decide those things.

4. You have a right to know the names of the dentists and other providers enrolled with

DentaQuest and their addresses.

5. You have a right to pick from a list of dentists that is large enough so that your child can

get the right kind of care when your child needs it.

6. You have the right to take part in all the choices about your child's dental care.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

7. You have the right to speak for your child in all treatment choices.

8. You have the right to get a second opinion from another dentist enrolled with

DentaQuest about what kind of treatment your child needs.

9. You have the right to be treated fairly by DentaQuest, dentists, and other providers.

10. You have the right to talk to your child's dentist and other providers in private, and to

have your child's dental records kept private. You have the right to look over and copy

your child's dental records and to ask for changes to those records.

11. You have a right to know that dentists, hospitals, and others who care for your child can

advise you about your child’s health status, medical care, and treatment. DentaQuest

cannot prevent dentists, hospitals, and others who care for your child from giving you this

information, even if the care or treatment is not a covered service.

12. You have a right to know that you are only responsible for paying allowable copayments

for covered services, up to benefit maximum limits. Dentists, hospitals, and others cannot

require you to pay any other amounts for covered services.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

CHIP Member Responsibilities

The Member and DentaQuest both have an interest in seeing their child's dental health improve.

The Member can help by assuming these responsibilities.

1. The Member must try to follow healthy habits. Encourage their child to stay away from

tobacco, and to eat a healthy diet.

2. The Member must become involved in the dentist’s decisions about their child's

treatments.

3. The Member must work together with DentaQuest’s dentists and other providers to pick

treatments for their child that they have all agreed upon.

4. If the Member has a disagreement with DentaQuest, they must try first to resolve it using

DentaQuest’s complaint process.

5. The Member must learn about what DentaQuest does and does not cover. The Member

must read the Member Handbook to understand how the rules work.

6. If the Member makes an appointment for their child, they must try to get to the dentist's

office on time. If they cannot keep the appointment, they must be sure to call and cancel

it.

7. The Member must report misuse of CHIP by dental and health care providers, other CHIP

Members, DentaQuest, or other CHIP plans.

If you think that you have been treated unfairly or discriminated against, call the U.S.

Department of Health and Human Services (HHS) toll‐free at 1‐800‐368‐1019. The Member can

also view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

Fraud and Abuse Reporting

Do you want to report Waste, Abuse, or Fraud?

Let us know if you think a doctor, dentist, pharmacist at a drug store, other health care

providers,

or a person getting benefits is doing something wrong. Doing something wrong could be waste,

abuse or fraud, which is against the law. For example, tell us if you think someone is:

• Getting paid for Medicaid and CHIP services that weren’t given or necessary.

• Not telling the truth about a medical condition to get medical treatment.

• Letting someone else use a Medicaid or CHIP Dental ID.

• Using someone else’s Medicaid or CHIP Dental ID.

• Not telling the truth about the amount of money or resources he or she has to get

benefits.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

To report waste, abuse, or fraud, choose one of the following:

• Call the OIG Hotline at 1‐800‐436‐6184 or

• Visit https://oig.hhsc.state.tx.us/ Under the box labeled “I WANT TO” click “Report

Waste, Abuse, and Fraud” to complete the online form.

• You can also report fraud directly to DentaQuest:

DentaQuest‐TX HHSC Dental Services

Attention: Utilization Review Department

P.O. Box 2906

Milwaukee, WI 53201‐2906

Toll‐free at 1‐800‐237‐9139

Providers may also send a fax to: 262‐241‐7366

To report waste, abuse or fraud, gather as much information as possible.

• When reporting about a provider (a doctor, dentist, counselor, etc.) include:

o Name, address, and phone number of provider.

o Name and address of the facility (hospital, nursing home, home health

agency, etc.)

o Medicaid number of the provider and facility, if you have it.

o Type of provider (doctor, dentist, therapist, pharmacist, etc.)

o Names and phone numbers of other witnesses who can help in the

investigation.

o Dates of events.

o Summary of what happened.

• When reporting about someone who gets benefits include:

o The person’s name.

o The person’s date of birth, Social Security number, or case number if you

have it.

o The city where the person lives.

o Specific details about the waste, abuse, or fraud.

J. Medicaid and CHIP Encounter Data, Billing, and Claims

Administration

Where to Send Claims/Encounter Data

DentaQuest receives dental claims in four possible formats. These formats include:

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

• Electronic claims via DentaQuest’s website (www.dentaquest.com).

• Electronic submission via clearinghouses.

• HIPAA Compliant 837D File.

• Paper claims (ADA Claim Form 2018, 2019, or newer)

Electronic Claim Submission Utilizing DentaQuest’s Internet Website

Participating Providers may submit claims directly to DentaQuest by utilizing the “Dentist”

section of our website. Submitting claims via the website is very quick and easy. It is especially

easy if you have already accessed the site to check a Member’s eligibility prior to providing the

service.

To submit claims via the website, simply log on to www.dentaquest.com. Once you have

entered

the website, click on the “Dentist” icon. From there choose your “State” and press

“Go”. You will

then be able to log in using your password and ID. First time users will have to register by

utilizing the Business’s TIN, State and Zip Code. DentaQuest should have contacted your office in

regards on how to perform Provider Self Registration Once logged in, select

“Claims/Pre‐

Authorizations” and then “Dental Claim Entry“. The Dentist Portal allows you to attach

electronic files (such as x‐rays in jpeg format, reports and charts) to the claim.

If you have not received instruction on how to complete Provider Self Registration, you can

access the guide at http://www.dentaquest.com/getattachment/State-

Plans/Regions/texas/Dentists-Page/New-Provider-Registration-Tip-Sheet.pdf. If you need further

assistance, please contact DentaQuest’s Customer Service Department at 1‐800‐896‐2374.

For Providers who are unable to submit electronically via the Internet or a clearinghouse,

DentaQuest will work with the Provider to receive their claims electronically via a HIPAA

compliant 837D or 837P file from the Provider’s practice management system. Please contact the

Systems Operations Department at 800‐417‐7140 or via e‐mail at

[email protected] to inquire about this option for electronic claim submission.

Electronic Authorization Submission Utilizing DentaQuest's Internet Website

Participating Providers may submit Pre‐Authorizations directly to DentaQuest by utilizing the

“Dentist” section of our website. Submitting Pre‐Authorizations via the website is very quick and

easy. It is especially easy if you have already accessed the site to check a Member’s

eligibility

prior to providing the service.

To submit pre‐authorizations via the website, simply log on to www.dentaquest.com. Once you

have entered the website, click on the “Dentist” icon. From there choose your ‘State” and press

“Go”. You will then be able to log in using your password and ID. First time users will have to

how to complete Provider Self Registration contact DentaQuest’s Customer Service

Department

at 1‐800‐896‐2374. Once logged in, select “Claims/Pre‐Authorizations” and then “Dental Pre‐

Auth Entry“.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

The Dentist Portal also allows you to attach electronic files (such as x‐rays in jpeg format,

reports

and charts) to the pre‐authorization. Please submit to:

[email protected]

Electronic Claim Submission via Clearinghouse

DentaQuest works directly with Emdeon (1‐888‐255‐7293), Tesia 1‐800‐724‐7240, EDI Health

Group 1‐800‐576‐6412, Secure EDI 1‐877‐466‐9656 and Mercury Data Exchange 1‐866‐633‐

1090, for claim submissions to DentaQuest.

You can contact your software vendor and make certain that they have DentaQuest listed as the

payer and claim mailing address on your electronic claim. Your software vendor will be able

provide you with any information you may need to ensure that submitted claims are

forwarded

to DentaQuest. DentaQuest’s Payor ID is CX014.

HIPAA Compliant 837D File

For Providers who are unable to submit electronically via the Internet or a clearinghouse,

DentaQuest will work directly with the Provider to receive their claims electronically via a HIPAA

compliant 837D or 837P file from the Provider’s practice management system. Please

[email protected] to inquire about this option for electronic claim submission.

NPI Requirements for Submission of Electronic Claims

In accordance with the HIPAA guidelines, DentaQuest has adopted the following NPI standards in

order to simplify the submission of claims from all of our providers, conform to industry required

standards and increase the accuracy and efficiency of claims administered by DentaQuest.

• Providers must register for the appropriate NPI classification at the following website

https://nppes.cms.hhs.gov/#/ and provide this information to DentaQuest in its

entirety.

• All providers must register for an Individual NPI. You may also be required to register

for a group NPI (or as part of a group) dependant upon your designation.

• When submitting claims to DentaQuest you must submit all forms of NPI properly and

in their entirety for claims to be accepted and processed accurately. If you registered

as part of a group, your claims must be submitted with both the Group and Individual

NPI’s. These numbers are not interchangeable and could cause your claims to be

returned to you as non‐compliant.

• If you are presently submitting claims to DentaQuest through a clearinghouse or

through a direct integration, you need to review your integration to assure that it is in

compliance with the revised HIPAA compliant 837D format. This information can be

found on the 837D Companion Guide located on the Provider Web Portal.

Paper Claim Submission

• Claims must be submitted on 2018, 2019, or later ADA approved claim forms.

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

• Member name, identification number, and date of birth must be listed on all claims

submitted. If the Member identification number is missing or miscoded on the claim

form, the patient cannot be identified. This could result in the claim being returned to

the submitting Provider office, causing a delay in payment.

• The paper claim must contain an acceptable Provider signature.

• The Provider and office location information must be clearly identified on the claim.

Frequently, if only the dentist signature is used for identification, the dentist’s name

cannot be clearly identified. Please include either a typed dentist (practice) name or the

DentaQuest Provider identification number.

• The paper claim form must contain a valid provider NPI (National Provider

Identification)

number. In the event of not having this box on the claim form, the NPI

must still be

included on the form. The ADA claim form only supplies two (2) fields to enter NPI. On

paper claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction

with a Type 1 NPI to identify the dentist who provided the treatment. For example, on a

standard ADA Dental Claim Form, the treating dentist’s NPI is entered in field 54 and the

billing entity’s NPI is entered in field 49.

• The date of service must be provided on the claim form for each service line submitted.

• Approved ADA dental codes as published in the current CDT book or as defined in this

manual must be used to define all services.

• List all quadrants, tooth numbers and surfaces for dental codes that necessitate

identification (extractions, root canals, amalgams and resin fillings). Missing tooth and

surface identification codes can result in the delay or denial of claim payment.

• Affix the proper postage when mailing bulk documentation. DentaQuest does not accept

postage due mail. This mail will be returned to the sender and will result in delay of

payment.

Claims should be mailed to the following address:

DentaQuest‐ TX HHSC Dental Program

P.O. Box 2906

Milwaukee, WI 53201‐2906

For questions, providers may contact DentaQuest Provider Services at 1‐800‐896‐2374.

Coordination of Benefits (COB)

The TX HHSC Medicaid/CHIP Dental Program/DentaQuest is the payer of last resort. Providers

should ask Members if they have other dental insurance coverage at the time of their

appointment. When TX HHSC Medicaid/CHIP Dental Program/DentaQuest is the secondary

insurance carrier, a copy of the primary carrier's Explanation of Benefits (EOB) must be

submitted with the claim. For electronic claim submissions, the payment made by the primary

DentaQuest USA Insurance Company

DentaQuest USA Insurance Company, Inc February 1, 2024

carrier must be indicated in the appropriate COB field. When a primary carrier's payment meets

or exceeds the HHSC Dental Services Program’s fee schedule, DentaQuest will consider the

claim

paid in full and no further payment will be made on the claim.

Receipt and Audit of Claims

In order to ensure timely, accurate remittances to each participating Provider, DentaQuest

performs an audit of all claims upon receipt. This audit validates Member eligibility, procedure

codes and dentist identifying information. A DentaQuest Customer Contact Center

Representative analyzes any claim conditions that would result in non‐payment. When

potential

problems are identified, your office may be contacted and asked to assist in resolving this

problem. Please contact our Customer Service department at 1‐800‐896‐2374 with any

questions you may have regarding claim submission or your remittance.

Each DentaQuest Provider office receives an “Explanation of Benefit” report with their

remittance. This report includes patient information and an allowable fee by date of service for

each service rendered.

Second Opinion Reviews and Regional Screening