DentaQuest Clears the Air on Medicaid Prepayment Review: No Prior Authorization Needed
A clarification has been released by DentaQuest which is a leading Medicaid dental benefits administrator, because of recent updates that they have made to their prepayment review and claim policies in New Mexico. The company has made it clear to its customers that the changes that they have made are to better the quality of care and best clinical practices. They have also made it clear that these changes do not restrict or change their benefits in any way.
Prepayment Review, Not Prior Authorization
The key of the clarification concerns the differentiation between prepayment review and prior authorization. DentaQuest has confirmed to providers that new policies imply prepayment review to be processed but not prior authorization for dental services. An essential part of the review is the supporting documentation or narrative on the medical necessity for the codes that are subject to review. Typically, when documentation is provided, the reviews do not hold up claims.
Streamlined Documentation Requirements
In addition, DentaQuest has shared a comprehensive list that outlines exactly what documentation will be needed for each prepayment code, as well as the criteria that will be used as part of the review process. This is to ensure that the process is made easier for providers and that claims are processed as they become. The company has restated that it is dedicated to working with the provider community as it stands by the common goal of enhancing oral health. DentaQuest recognizes that it has received feedback from the community of providers and would like to continue working with all concerned parties to address any concerns that may occur.
Key Takeaways for Providers:
- No changes to benefits: The updates do not restrict or alter existing benefits.
- No prior authorization: Prepayment review does not require prior authorization.
- Include supporting documentation: Submitting proper documentation with claims will expedite the review process.
- Review grid available: DentaQuest has provided a detailed grid outlining documentation requirements for each prepayment code.
Here’s a table outlining the documentation needed according to the new rules, organized by code:
| Code | Required Documentation |
| D0367 | Narrative of medical necessity indicating implant case, skeletal fracture, craniofacial anomaly, or pathology, along with evidence that conventional radiographs are insufficient. |
| D2950 | Narrative of medical necessity, pre-op x-ray(s) showing clinical crown breakdown at a level necessitating core buildup for crown retention. |
| D3220 | Narrative of medical necessity, pre-op x-ray(s), assessment of the long-term prognosis of the tooth, and necessity of the root canal therapy. |
| D7140 | Narrative of medical necessity explaining therapeutic indication (prolonged retention, blocking eruption, severe decay, abscess with bone loss, etc.), pre-op periapical radiograph. |
| D7210 | Narrative of medical necessity, pre-op x-ray(s) showing the need for a surgical extraction (e.g., root dilaceration, endodontic treatment, >75% crown decay). |
| D7220 | Narrative of medical necessity, pre-op x-ray(s) adhering to ORM clinical criteria for impacted third molar extractions. |
| D7230 | Narrative of medical necessity, pre-op x-ray(s). |
| D7240 | Narrative of medical necessity, pre-op x-ray(s). |
| D7241 | Clinical notes outlining the unusual surgical complication necessitating D7241 coding, and pre-op x-ray(s). |
| D7250 | Same as D7210 (narrative of medical necessity, pre-op x-ray(s) justifying surgical extraction). |
| D7310 | Narrative of medical necessity, pre-op x-ray(s), documentation of at least 4 teeth removed in a quadrant, narrative supporting prosthetic placement, an indication of the separate procedure. |
| D7961 | Narrative of medical necessity, pre-op x-ray(s), documentation of full eruption of permanent incisors/cuspids for diastemas, pediatrician letter for infants 0-18 months (if applicable). |
| D9223 | Narrative, treatment record (including anesthesia records) meeting the specific criteria outlined for sedation/nitrous oxide use. |
| D9230 | Narrative of medical necessity. |
| D9239 | Narrative, treatment record (including anesthesia records). |
| D9243 | Narrative, treatment record (including anesthesia records). |
| D9610 | Description of the drug with the claim to ensure it matches approved criteria. |
Capline Simplifies Claims Processing
Capline’s team of experts has put together a range of services designed to ensure your claims are processed quickly, accurately, and with a minimum of stress for your practice. Our services are designed to ensure that your practice can:
- Meet the requirements of DentaQuest’s updated policies and guidelines
- Provide the documentation required to qualify for a prepayment review
- Identify and address potential issues before they result in denied claims
- Submit appeals quickly and effectively to get your claims paid as quickly as possible
We believe that by partnering with Capline, you can both reduce the administrative burden and the number of claim denials and focus on providing high-quality dental care to your patients.
This clarification is regarding DentaQuest to help dentists throughout New Mexico improve the oral health of the residents. The company considers dentists “a critical stakeholder group to help in the delivery of care, prevention, education, and cost management”. The reason for the clarification is the persistence of some of the above-mentioned concerns from New Mexico providers, manifesting itself in dissatisfaction with the recently introduced policy changes.
It is vital to note that Capline will follow the requirements resulting from these changes to the claims review process and ensure that the implementation of these changes does not affect the benefits covered by your claims or cause unnecessary delays. We hope that the clarifications and the provision of this additional information will help dentists and other providers in New Mexico better understand the required procedure and streamline their insurance claims process.
