Utilization Management Prior Authorization and Review Procedures
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Governs DentaQuest Dental's processes for prior authorization, prepayment and retrospective review of dental services requiring medical necessity review; applies to providers and members across all lines of business (Kentucky referenced in header).
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Covered when ALL of the following are met
Clinical Review Specialists use clinical algorithms; Clinical/Dental Consultants review and sign clinical denials.
Emergent determinations completed within 24 hours.
Process and Timeframe Criteria
Authorization timing and extensions
Nonurgent pre-service and post-service timeframes may be extended up to 14 calendar days under specified conditions.
All necessary information is limited to three items per KRS 304.17A-607(1)(i): results of any face-to-face clinical evaluation; any required second opinion; and any other information necessary to make a utilization review determination.
DentaQuest will not deny a claim for failure to obtain preauthorization when the preauthorization requirement was not in effect and posted on the date of service. DentaQuest and the health plan maintain publicly accessible information identifying services and codes that require preauthorization, including the effective and (if applicable) termination dates for each requirement.
A clinical denial is issued when the submitted clinical data do not demonstrate the medical necessity of the requested service(s) or when the provider fails to supply information required to fully evaluate medical necessity. All clinical denials are routed to and must be reviewed and determined by a licensed Clinical and/or Dental Consultant, and such denials must be signed off by that consultant prior to issuance.
If an urgent preauthorization request lacks necessary clinical information, DentaQuest will deny the request and will provide written notice to the enrollee and provider explaining the reason for the denial. For nonurgent requests, DentaQuest may extend the timeframe to request additional information (see Process and Timeframe criteria), but may deny the request if required information is not provided within the allowed period; members retain the right to appeal denials.
Provider Responsibilities and Authorization Process
Prior authorization required; submit requests as prior authorization or prepayment review
Providers must obtain prior authorization (prospective review) for services specified by the plan; requests may be submitted as prior authorization or prepayment review per the Office Reference Manual. Nonemergency treatment begun before UM review is at the provider's financial risk. For urgent/emergent services, treat the member and submit a completed claim and any necessary documentation marked 'Prepayment Review.'
- Submit authorization requests according to the Plan design and Provider Office Reference Manual.
- Mark claims 'Prepayment Review' when submitting urgent/emergent services treated before authorization.
Submit authorization requests and expect clinical review and consultant routing for denials
Submit authorization requests for services requiring UM review and be prepared to provide supporting clinical documentation; the CRS reviews requests against Plan benefit design and clinical algorithms and routes requests needing denial to a licensed Clinical/Dental Consultant within one business day.
- Authorization requests are reviewed by the Clinical Review Specialist (CRS) per Plan design and clinical algorithm.
- If denial is indicated, request is routed to a licensed Clinical/Dental Consultant within one business day; all clinical denials must be signed off by that consultant.
Include required clinical documentation with authorization requests
Authorization requests must include supporting clinical documentation — including results of any face-to-face clinical evaluation and any required second opinion — and any other information necessary for utilization review; DentaQuest may request additional information and will notify the member/provider in writing if an extension is taken.
- Include results of any face-to-face clinical evaluation.
- Include any second opinion that may be required.
- Provide any other information determined to be necessary to make a utilization review determination.
Missing clinical information may lead to denial or extension — urgent requests denied if incomplete
Requests that lack required clinical information may be denied; urgent preauthorization requests missing clinical information will be denied and written notice will be provided. For standard or post-service requests missing information, DentaQuest may extend timeframes up to 14 calendar days but may deny the request if all necessary information is not received within the timeframe.
- Urgent preauthorization requests lacking clinical information will be denied and the enrollee/provider notified in writing.
- Standard preauthorization or post-service requests may have the nonurgent timeframe extended up to 14 calendar days when appropriate; written notice of extension and grievance rights will be provided.
- DentaQuest may deny the request if the necessary information (face-to-face results, second opinion, other required information) is not received within the timeframe; the member may appeal.
Key Definitions
Background and Rationale
DentaQuest uses clinical algorithms—series of yes/no clinical questions developed from current ADA/CDT nomenclature and generally accepted practice guidelines—to determine medical necessity. Clinical Review Specialists apply these algorithms when evaluating requests, and when a request appears to require denial based on medical necessity it is escalated to a licensed Clinical or Dental Consultant for final determination.
Urgent or emergent conditions (for example, treatment for pain, swelling, infection, uncontrolled hemorrhage, or traumatic injury or circumstances a prudent layperson would consider immediate care) should be treated promptly; such cases are processed under the emergent timeframe and may be submitted as Prepayment Review when appropriate.
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