Denial and Approval Letters
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Governs the process and content for written authorization determination communications (approvals and denials) sent to Providers and Members for all DentaQuest Dental lines of business and states.
No material clinical or coverage changes in this revision.
Notification Content & Timelines
Approval notification criteria
Covered when ALL of the following are met:
ALL of the following
- Recipient: Provider and Member.
- Provider timing: written notification sent within two (2) business days for standard determinations; same day for urgent (24-hour) determinations.
- Member timing: written notification sent within two (2) business days for standard determinations; same day for urgent (24-hour) determinations; a copy of the member approval letter is also sent to the requesting provider.
- Provider written notice must include: Member name; Member subscriber ID; Member date of birth; Provider name; Service location; Authorization reference number; Determination date; List of service(s) approved; Expiration date of the approval; Statement that approval is not a guarantee of payment and payment is contingent upon contract terms and member eligibility.
- Member approval letter must include: Member name; Provider name; Date of request; Authorization reference number; List of service(s) approved; Timeframe the authorization approval is valid; Statement that approval is not a guarantee of payment and payment is contingent upon contract terms and member eligibility; Language tag lines (top 15 languages) with instructions for translation; Discrimination notice.
Denial notification criteria
Denials are communicated in writing to the Member (NOA) and the requesting Provider; timelines mirror approval notifications.
ALL of the following
- Recipient: Member (Notice of Action) and requesting Provider (copy of member letter).
- Timing: within two (2) business days for standard determinations; same day for urgent determinations; Utilization Management delivers written notifications to mail room to meet timelines.
- NOA (member letter) must include: List of service(s) requested; Identification of the Provider requesting the service(s); Date the request was received; Denial reason specific to the service denied (clinical denials include clinical rationale in lay terms; administrative denials identify the specific benefit limitation); Identification and credentials of the dental consultant for clinical denials; Statement that provider may contact DentaQuest to discuss the clinical decision with the dental consultant; Identification of any applicable State citation relating to the denial; Member appeal rights including process for filing complaint/grievance and internal appeal, addresses and toll-free number; Statement with address and toll-free number to request a copy of the clinical criteria used; State Fair Hearing information, if applicable; Reference to external appeal processes for final adverse determinations; Reference to external organizations that may assist the member; Information on how to obtain the NOA in a language other than English; Language tag lines (top 15 languages) with translation instructions; Discrimination notice; Right to obtain copies of documents/records relevant to the determination upon request and free of charge; Right to continuation of benefits pending appeal and how to request continuation, as applicable.
- Provider Determination Letter (PDL) handling and content: PDLs may be generated within two hours but within one business day of the determination; PDLs may be faxed or mailed; if faxed, a record of successful fax date/time is retained; if fax fails or no secure fax available, the PDL is printed and mailed; if provider fax cannot receive HIPAA information, the PDL will not be faxed and will be mailed instead; PDL must include: Member name; Member subscriber ID; Member date of birth; Provider name; Service location; Authorization reference number; Determination date; List of service(s) denied; Denial reason; Appeal information.
Codes & Timing Metrics
Provider Notification & PDL Handling
Provider notification timing and delivery
Providers are sent written notification of approvals within two (2) business days for standard preauthorization determinations and same day for urgent (24-hour) determinations. Provider Determination Letters (PDLs) for denials/decisions may generate within two hours but will be produced within one business day.
Denial communications to provider
When a standard authorization is denied, DentaQuest sends the member a Notice of Action (NOA) and also sends a copy of that member NOA to the requesting provider. The Provider Determination Letter (PDL) sent to providers includes member and request identifiers, the list of services denied, the denial reason, and appeal information.
- Member name, subscriber ID and date of birth included on the PDL
- Provider name, service location and authorization reference number included
- List of service(s) denied, denial reason, and appeal information must be provided
PDL faxing and mailing rules
PDLs may be faxed or mailed. If a PDL is faxed, DentaQuest retains a record of the date/time of the successful fax; if the fax fails, the PDL is printed and mailed. If no fax number is available or the provider’s fax cannot receive HIPAA information (not secure), the PDL is printed and mailed instead. PDLs are not mailed in addition to being faxed unless the provider requests mailing.
- Retain date/time record for successful fax transmissions
- If fax fails, print and mail the PDL
- If no fax or fax not secure, do not fax — print and mail instead
- Do not mail in addition to fax unless requested by the provider
Key Terms
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