Appeals and Grievances

A Grievance is an action you take when you want to submit a complaint about your dental provider, the care they provided, DentaQuest, or other dental care issues. Grievances are not for issues related to claim decisions. 

An Appeal, also called a Reconsideration, is an action you can take when you do not agree with a decision that has been made on a Prior Authorization or a Claim.

• When a service you asked for is denied or only partly approved. This includes decisions based on the type of service, if it’s needed, or how and where it is provided.
• When a service that was already approved is reduced, stopped, or ended.
• When a payment for a service is denied, either fully or partially. If the claim does not meet the definition of a “clean claim,” it is not considered an adverse benefit determination. A clean claim is one that has all the necessary information to process the payment without needing further details, corrections, or investigation.
• When services are not provided quickly enough as defined by the State. 
• When a managed care organization or other health plan fails to respond to grievances or appeals within the required timeframes.
• When your request to challenge costs (like co-pays, premiums, deductibles, etc.) is denied.
   

Grievance

A Grievance is an action you take when you want to submit a complaint about your dental provider, the care they provided, DentaQuest, or other dental care issues. Grievances are not for issues related to claim decisions. 

To submit a complaint or grievance regarding a service or a provider, you can call DentaQuest customer service at 1-855-225-1729 (State Relay 711). The customer service agent can take the details of your complaint and file on your behalf. If you would like to file the complaint online, you can do so in the Member Portal. Go to the Grievances and Reconsiderations portion of the Help Page and click on Submit a Help Request. You can detail the complaint and attach any documentation necessary. When the investigation is complete, a letter will be sent to the member explaining the decision. 

Members or their representatives may also submit a written grievance to:  
DentaQuest Complaints and Appeals Department  
11100 W. Liberty Drive  
Milwaukee, WI 53224 

Appeals

An Appeal, also called a Reconsideration, is an action you can take when you do not agree with a decision that has been made on a Prior Authorization or a Claim. Members have the right to appeal any adverse determination made on a claim or pre-authorization, whether in whole or in part. We will not take any action against you because you request an appeal. Your request for an appeal must be received within 60 days of the date of your decision letter. You, your representative, or provider can ask for an appeal by phone, fax, or writing to:

DentaQuest Complaints and Appeals Department  
11100 W. Liberty Drive  
Milwaukee, WI 53224  
Phone: 1-855-225-1729 (State Relay 711) Fax: 1-262-834-3452

If you ask for an appeal by phone, we will send you a letter describing your request. We will send this letter to you in two (2) business days. You, your representative, or provider will need to sign and return this letter to confirm your request in writing. When we receive your appeal request, we will send you a letter in two (2) business days telling you we received the request. We may need more facts about your case. We may contact you or your provider to get these extra facts. We will decide your reconsideration within ten (10) business days of receipt. We will send you a letter with our decision.

The member’s guardian, dentist, or someone they want to represent them can call Member Service at 1-888-307-6561, TTY 711 (toll-free) or write to DentaQuest at the address listed above to request a DentaQuest appeal. In addition, DentaQuest Member Service is available to assist with the appeal filing process.

If you want someone else to represent you, let DentaQuest know in writing. Include their name, address, and phone number. If you want to access any dental records, you or a legal guardian must give written permission to your dentist. DentaQuest cannot take away your benefits because you file an appeal. 

A State Fair Hearing is a court hearing with an Administrative Law Judge. If you don’t agree with the appeal decision your health plan made, you can ask for a State Fair Hearing. To ask for a State Fair Hearing, you have to wait until you get a decision from your health plan about your appeal. You must ask for a State Fair Hearing within 120 days from when you receive the appeal decision from your health plan. Your request must be in writing. You can submit a request online at www.colorado.gov/oac/oac-form-links. If you mail your request, be sure to sign it and include your:

• Name
• Mailing address 
• Phone number 
• Email address 
• Health First Colorado ID and Case ID 
• Reason for your appeal 
• Copy of the notice with the decision you are appealing
   

After you file an appeal, the Office of Administrative Courts will send back copies of the documents you filed.

Send your request to:

Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
Phone: 303-866-2000
Fax: 303-866-5909
Email: oac-gs@state.co.us

The Office of Administrative Courts will send you a letter about the hearing. They will give you a hearing date. Before and during the hearing, you or the person you choose can give information to support your case. The Judge will make an Initial Decision. The Department of Health Care Policy and Financing will review the Judge’s decision and issue a Final Agency Decision.

Expedited Hearings

If waiting for a regular hearing could seriously risk your life or health, you can ask for an expedited (faster) hearing.

To Request an Expedited Hearing:

• Write Your Appeal Letter using the instructions listed in the appeals process above
• Include in Your Appeal Letter:
• Your request for an expedited hearing
• Explain how and why your life, health, or ability to function would be seriously at risk without a faster appeal
• Give more information to explain why you need the expedited hearing. If your request for an expedited hearing is approved, you’ll get a phone call to schedule the hearing date and time. If it’s denied, you’ll get a written notice. You can still have a regular hearing if the expedited request is denied.
   

If you don’t agree with the appeal decision your health plan made, you can ask for a State Fair Hearing. To ask for a State Fair Hearing, you must wait until you get a decision from your health plan about your appeal. You must ask for a State Fair Hearing within 120 days from when you receive the appeal decision from your health plan. Your request must be in writing. You can submit a request online at www.colorado.gov/oac/oac-form-links. If you mail your request, be sure to sign it and include your:

• Name
• Mailing address
• Phone number
• Email address 
• Health First Colorado ID and Case ID
• Reason for your appeal
• Copy of the notice with the decision you are appealing
   

After you file an appeal, the Office of Administrative Courts will send back copies of the documents you filed.

Send your request to:

Office of Administrative Courts 
1525 Sherman Street, 4th Floor  
Denver, CO 80203 
Phone: 303-866-2000 Fax: 303-866-5909  
Email: oac-gs@state.co.us

The Office of Administrative Courts will send you a letter about the hearing. They will give you a hearing date. Before and during the hearing, you or the person you choose can give information to support your case. The Judge will make an Initial Decision. The Department of Health Care Policy and Financing will review the Judge’s decision and issue a Final Agency Decision.

A member can file an appeal/grievance online by submitting a help request in their Member Portal. They can do this by clicking the "Contact Us" button at the bottom of the page. Click "Create a Help Request" and filling out the form. On this form, you can also add any attachments or documentation you might find helpful to your appeal/grievance. Please click here to register and access your portal: Colorado Member Portal