CHIP Complaints and Appeals

Complaint Process

What should I do if I have a complaint?
We want to help. If you have a complaint, please call us at 1-800-508-6775 (toll-free) 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.
 
Who do I call?
If you still have a complaint after you’ve gone through the DentaQuest complaint process, call the Texas Department of Insurance at 1-800-252-3439 (toll-free). If you want to make your complaint in writing, please send it to the following address:
 
Texas Department of Insurance
P.O. Box 149091
Austin, Texas 78714-9091
 
Can someone from DentaQuest help me file a complaint?
A DentaQuest Member Advocate can help you file a complaint. Please call us at 1-800-508-6775 (toll-free). 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.

You can call us to tell us about your complaint or you can send your complaint in writing to:
 
DentaQuest-TX
Attn: Complaints & Grievances
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759
 
You may use this form if you would like to write to us:
 
TX CHIP Complaint Form
 
Who do I call?
Call us toll-free at: 1-800-508-6775
 
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. Call our Member Call Center toll free at 1-800-508-6775.
 
If I don’t like what happens with my complaint, who else can I call?
You may file an appeal if you are not satisfied with our response to your complaint. You can also file a complaint with the Texas
Department of Insurance.
 
How can I file a complaint with the Texas Department of Insurance
after I have gone through the DentaQuest complaint process?
If you still have a complaint after you’ve gone through the DentaQuest complaint process, call the Texas Department of Insurance at 1-800-252-3439 (toll-free). If you want to make your complaint in writing, please send it to the following address:
 
Texas Department of Insurance
P.O. Box 149091
Austin, Texas 78714-9091
 
You may file an appeal if you are not satisfied with our response to your complaint.

 

Appeal Process

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

TX CHIP Appeal Form
 
Or call us toll-free at: 1-800-508-6775
 
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.

When can I ask for an appeal?
You have the right to ask for an appeal if you are not happy with the decision to your complaint. You can also ask for an appeal due to an adverse determination. This is a denial where DentaQuest decides that the service is not medically necessary.

However, you cannot appeal a decision related to:
  • Annual maximum benefits.
  • Member eligibility.
 
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. 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: 1-800-508-6775

You may call our Member Call Center to ask for an appeal. Within five (5) business days after you call, we will send you an appeal form. We must get your completed, signed appeal form to confirm your appeal request. (If your appeal request is related to a dental emergency, we do not need a completed, signed form to process the appeal). We will send you a letter to let you know we got your appeal. We will make a decision no later than the 30th calendar day after the date we get the appeal.
 
Can someone from DentaQuest help me file an appeal?
A DentaQuest Member Advocate can help you file an appeal. Please call our Member Call Center for help. The toll-free number is 1-800-508-6775. Tell us that you want to file an appeal and one of our Member Advocates will help you file the appeal.

What else can I do if I’m still not happy?
An Independent Review Organization (IRO) is an outside organization that the Texas Department of Insurance (TDI) picks to review your health plan’s denial of a service you and your Main Dentist feel is medically necessary. This organization is not related to your dentist or your health plan. There is no cost to you for this independent review.

You can ask for a review by an IRO after you complete the appeal process with DentaQuest, or if DentaQuest has denied a service that you think is life-threatening.

To ask for an IRO, you must fill out the “Request for a Review by an Independent Review Organization” form that is sent with your Notice of Action letter. A Notice of Action letter is what we mailed to you to tell you we denied the services your dentist asked us for. You can also contact our Member Call Center and request an IRO form be sent to you. Our toll-free number is 1-800-508-6775.

Once we get the completed IRO form, we will send it to the Texas Department of Insurance (TDI). TDI will give your case to an IRO
agent. The IRO has 20 days to make a decision and eight (8) days for life-threatening cases.

 

Expedited Dental Plan Appeal

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

How do I ask for an expedited Appeal?
You can call us to file an expedited appeal. We do not need your appeal in writing for an expedited appeal. If you need help in filing an expedited appeal, call our member call center for help. The toll-free number is 1-800-508-6775. Tell us that you want to file an expedited appeal.

How long does an expedited appeal take (timeframe)?
We will make a decision within three (3) business days after we get your request for an expedited appeal.

What happens if DentaQuest says it won’t do an expedited appeal?
If DentaQuest does not feel that your appeal is life-threatening, we will let you know within three (3) business days after we get your request for an expedited appeal. Your appeal will still be worked on, but the resolution may take up to 30 days.

Who can help me file an Expedited Appeal?
If you or your representative need help in filing an expedited appeal, call our member call center and one of our Member Advocates can help. The toll-free number is 1-800-508-6775. Tell us that you want to file an expedited appeal.

 

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