Medicaid Complaints and Appeals

Complaint Process

What should I do if I have a complaint?
We want to help. If you have a complaint please contact us to tell us about your problem. A DentaQuest Member Advocate can help you file a complaint. Most of the time, we can help you right away or within a few days at the most.
 
To file a complaint or grievance you can:
 
Call us at:
Medicaid Dental Plan
1-800-516-0165 (toll-free)
 
7-1-1 (TDD/TTY toll-free)
 
Or you can a file paper form by filling it out and submit it to us.
 
TX Medicaid Complaint Form
 
What do I need to do to file a complaint, and how long will the process take?
We will process your complaint within thirty (30) calendar days from the day we get it. Here is what will happen:
  • You send us a written complaint.
  • We will send you a letter within five (5) business days. Our letter will say that we got your written complaint.
  • We will review the details of your complaint.
  • We will send you an answer within thirty (30) calendar days.
Our response to your complaint will be in a letter. That letter will give:
  • Our decision about your complaint.
  • The reasons for our decision.
  • The specialty area of any dentist we asked to help us with your complaint.
  • Information about filing an appeal.
We will send you a one-page form that you must sign and return to us. The form will tell us that you give permission to the person you name to represent you and your child during the complaint process. If you have any questions during the complaint process, please call us at 1-800-516-0165.
 
Who do I call?
If you receive benefits through Medicaid’s STAR, STAR+PLUS, STAR Health, or STAR Kids program, call your medical or dental plan first. If you don’t get the help you need there, you should do one of the following:
 
Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).

Online: Online Submission Form (only works in Internet Explorer)

Mail: Texas Health and Human Services Commission 
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
 
Fax: 1-888-780-8099 (Toll-Free)
 

Appeal Process

What is an appeal?
An appeal is the formal process by which a Member or his or her representative requests a review of DentaQuest’s actions.
 
What can I do if DentaQuest denies or limits a service for my child that the dentist has asked for? Can I just ask for an appeal or does it have to be in writing?
You can ask for an appeal in writing, or you can call and ask DentaQuest for an appeal. We will send you a one-page appeal form that you, your child’s dentist, or someone else representing you can fill out and return to us.
 
TX Medicaid Appeal Form
 
Our address to mail your appeal to is:
 
DentaQuest-TX
Attn: Appeal Department
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
 
Or call us toll-free at: 1-800-516-0165
 
How will I find out if services are denied?
We will send you and your dentist a letter. You can also call our Member Call Center and we can tell you the status of your authorization. Call us at 1-800-508-0165.
 
What are the time frames for the appeal process?
Once we get your appeal, we will process and respond within 30 calendar days. You may ask for an extension, or we may tell you that we need more time in order to get more information. We will only ask for an extension if the delay will help you.
 
Are you a Medicaid member and want to ask for a State fair hearing?
Call DentaQuest toll free at 1-800-516-0165
 
Mail a letter to DentaQuest at:
DentaQuest TX Dental Services
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
ATTN: Fair Hearing
 
If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. You can get more details about the process for complaints, grievances and about the Fair Hearing Process by reviewing your member handbook. 
 
 

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