How dental prior authorization works in Colorado Medicaid

What prior authorization does—and does not—mean

Prior authorization asks the dental plan to decide whether a proposed service meets benefit and clinical criteria before it is performed. Reviews may consider records such as X-rays, periodontal measurements, photographs, tooth history, narratives, or orthodontic measurements.

After authorization, payment also depends on enrollment, provider status, service date, the care delivered, benefit-year limits, other coverage and accurate billing. Your dental team can help check these details before treatment.

Before-treatment authorization and after-treatment review are different

Before-treatment authorization means the dental office sends the proposed non-emergency service and supporting records to DentaQuest and waits for a decision before providing that service.

Some services instead use review after treatment and before the claim is paid. In that route, the dentist completes the service and submits the clinical records with the claim for DentaQuest to review. This is not a preapproval, so ask the office which review route applies to each part of the plan.

• Many non-orthodontic authorizations are issued for a typical 180-day span. Orthodontic authorizations can use a 1,080-day span. The dates on the member's written determination always control.
• A multistage service must fit within its approval dates, and the member must remain eligible when the covered service is actually completed or delivered—not only when treatment planning begins.
• For a denture, check eligibility on the delivery date. For a crown, use the placement date. For endodontic care, use the date the root-canal treatment is completed.

The usual workflow

1. 1

   The dentist evaluates and recommends care

   The dentist's findings and treatment plan show which tooth, area of your mouth, or dental appliance—such as a denture—needs care.

2. 2

   The office checks the current rule

   The provider determines whether the procedure needs prior authorization for your age and program.

3. 3

   The provider submits supporting records

   Missing or unclear documentation can delay a decision or lead to a request for more information.

4. 4

   DentaQuest issues a determination

   Ask the office whether the request was approved, partially approved, denied, or still pending before scheduling non-emergency treatment.

5. 5

   Review the written notice

   A notice should explain the decision and any available appeal or fair-hearing rights. Follow the deadlines in that notice.

Emergency care follows different rules

The current adult and children's benefit summaries state that prior authorization is not required in emergency situations. Whether a claim qualifies as emergency treatment depends on the clinical facts and correct billing—not simply on the time of day or the word “urgent.”

Do not delay emergency evaluation while trying to obtain routine authorization. Contact a dental provider; if you cannot reach one and the situation may be dangerous, go to the nearest emergency department or call 911 for life-threatening symptoms.

Waiting for approval—or received a denial?

If you have not received a decision, ask the dental office to check the request rather than guessing when treatment can start. If a decision has arrived, ask the team to explain what it means for each part of your treatment plan.

• Ask when the request was submitted, which treatment it covers, whether it is still pending, and whether the office needs to send more information. Agree on when to check again.
• Confirm that DentaQuest has current contact information for you.
• Review the notice for the decision, next steps and any response deadline.
• Ask whether more records, a corrected request, a covered alternative, or an appeal is appropriate.
• Use the phone number and deadlines on the notice; appeal deadlines can be short and fact-specific.