Health First Colorado 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 concerns. Grievances are not for issues related to decisions made about services under your dental plan. For example, you believe the dental work you had done was of poor quality.

A reconsideration is an action you can take when you do not agree with a decision DentaQuest made about a service under your dental plan.  For example, when a service you asked for is denied.

Choose one of these ways to submit your grievance:

• Call DentaQuest at 855-225-1729 (State Relay 711)
• Online through the Member Portal portion of the Help Page, clicking "Contact Us", and then "Create Help Request"
• In writing:  
  DentaQuest Complaints and Appeals Department
  11100 W. Liberty Drive
  Milwaukee, WI 53224
   

 Your request for a reconsideration must be received within 60 days of the date of your decision letter. You, your authorized representative, or your provider can ask for a reconsideration.

Choose one of these ways to submit your reconsideration request:

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

If you ask for a reconsideration, we will send you a letter describing your request. We will send this letter to you in 2 business days. 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 10 business days of receipt. We will send you a letter with our decision.

You or your provider can request copies of the documentation and criteria we used to make our decision by calling DentaQuest at 855-225-1729 (State Relay: 711). We will provide the documentation and criteria at no cost to you or your provider.

Early and Periodic Screening, Diagnostic and Treatment Review

If the member is 20 years of age or younger, we reviewed their request for medical necessity under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) regulations at 10 CCR 2505-10, Section 8.280.4.E.

EPSDT ensures children enrolled in Health First Colorado receive all coverable Medicaid services including preventive, screening, diagnostic, and comprehensive treatment services, dental, vision, mental health, and developmental and specialty services that are medically necessary, even if the service is not available under the State plan to other Medicaid eligible members. Medical necessity is determined on a case-by-case basis. These services may be covered at no cost without arbitrary service limits.

For help with EPSDT services, contact DentaQuest at 855-225-1729 (State Relay 711). Learn more at hcpf.colorado.gov/epsdt.

You or your authorized representative has the right to ask for an expedited (faster) reconsideration. You can ask for an expedited reconsideration if a delay would increase the risk to your health. You can ask for an expedited reconsideration by calling DentaQuest at 855-225-1729 (State Relay: 711). 

We will make a decision about your expedited reconsideration within 3 business days from when we received it. We will call you and send you a letter telling you, our decision. If your request for an expedited reconsideration is denied, we will process your request in the standard time frame. You will have the right to file a grievance if you do not agree with taking more time to decide your reconsideration.

If you agree with the reconsideration decision, you do not need to do anything else. If you think the decision is wrong, you have the right to request a State Fair Hearing. A State Fair Hearing is when an Administrative Law Judge reviews DentaQuest’s decision.  You must file your appeal in writing for a State Fair Hearing within 60 days of the date of your decision letter. Your letter must include:

• Your Name
• Your Signature (if mailing or faxing)
• Your Mailing address
• Your Phone number
  
  

Helpful to include, but not required:  

• A case number or member ID
• Reason you disagree with the decision
• A copy of the decision letter
• A request for an interpreter or other accommodations (if needed)
  
  

Choose one of these ways to submit your letter:

• Mail and In-person:
• Office of Administrative Courts
  1525 Sherman Street, 4th Floor
  Denver, CO 80203
  Phone: 303-866-2000
• Fax: 303-866-5909 (10 pages or fewer; otherwise, mail your request)
• Email: oac-gs@state.co.us
  
  

You have the right to ask someone to request the State Fair Hearing on your behalf as your authorized representative.  You can also ask your provider to request the State Fair Hearing for you.  At the State Fair Hearing, you can speak for yourself or ask your authorized representative or provider to speak on your behalf.

The Office of Administrative Courts will contact you by mail with the date, time and place for your hearing with the Administrative Law Judge.

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

To request an expedited hearing:

• Write the letter of appeal using the instructions above for how to appeal
• Include in your letter of appeal:
  • Your request for an expedited hearing
  • Explain how and why your life, health, or ability to regain, attain or maintain maximum function would be serious risk if you do not have an expedited (faster) hearing
  • Provide additional information to explain why you need an expedited hearing
  • Mail, fax, email or bring your letter using the same instructions above for how to appeal

If your request for an expedited hearing is approved, you will be contacted by phone to set up a hearing date and time.

If your request for an expedited hearing is denied, you will still get a formal hearing through the Office of Administrative Courts. They will mail you a letter with the date, time and place for your hearing with the Administrative Law Judge.

I’ve recently switched from CHP+ to Health First Colorado (or from Health First Colorado to CHP+), what grievance process do I follow?

When filing your grievance, please use the process of the program you were under when the service occurred. For example, if you had a procedure done while under Health First Colorado and you want to file a grievance you should use the Health First Colorado process. Please contact customer service if you need support. Call 855-225-1729 (State Relay: 711), between the hours of 8a to 5p MT.

I’ve recently switched from CHP+ to Health First Colorado (or from Health First Colorado to CHP+), what reconsideration (or appeal) process do I follow?

When filing your reconsideration (or appeal), please use the process of the program you were under when the service occurred. For example, if you had a procedure denied while under Health First Colorado and you want to file a reconsideration (or appeal), you should use the Health First Colorado process. Please contact customer service if you need support. Call 855-225-1729 (State Relay: 711), between the hours of 8a to 5p MT.