Verbal Notification of Prior Authorization Determinations
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Defines DentaQuest's process for verbally notifying members and providers of prior authorization determinations, applying to government program members and associated providers across all states.
No material clinical or coverage changes in this revision.
Verbal Notification Procedure Requirements
Verbal notification procedure requirements
DentaQuest policy and procedures require the following for prior authorization verbal notifications:
Verbal Notification and Outreach for Prior Authorizations
Verbal notification and outreach for prior authorizations — provider/member obligations
DentaQuest requires providers and members to be verbally notified of prior authorization determinations; the organization conducts daily outreach using claims data, records all calls, and logs call outcomes so providers/members may be contacted and the results documented for Customer Service and Audit review.
- DentaQuest uses good faith efforts to notify members and providers of prior authorization determinations. [Procedural requirement]
- Outreach efforts are made daily using claims data extracted from DentaQuest claims payment records transmitted to a subcontractor. [Operational requirement]
- All calls are recorded and both live and recorded calls are monitored for quality assurance; DentaQuest maintains consistent QA standards and performance guidelines. [Quality assurance requirement]
- All calls are logged with the time and outcome recorded in DentaQuest member and provider files and made available to Customer Service and Audit personnel. [Documentation/access requirement]
Outreach Efforts and Quality Assurance Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.