Colorado Medicaid dental glossary

Benefit and coverage terms

The interactive glossary below includes common words from Health First Colorado dental materials. A benefit is a service category the program can pay for under its rules. Coverage is the application of those rules to a member, service, provider, and date. Medical necessity means the care meets program clinical standards; it is not established only by preference or by the presence of a diagnosis.

A benefit maximum is the most the program pays for services subject to that maximum during a defined period. As of July 1, 2026, standard adult dental coverage uses a $3,000 July–June annual maximum, with qualifying emergency treatment and covered removable dentures outside that dollar limit. Those exceptions still have other requirements.

Authorization, claim, and decision terms

• Prior authorization: plan review required before certain care; approval can have code, date, provider, unit, and clinical conditions.
• Claim: the request a provider sends for payment after a service, using procedure codes and other required information.
• Allowed amount: the amount recognized under the program's payment rules, which can differ from an office's standard fee.
• Adverse benefit determination: a denial, reduction, suspension, or termination of a requested or authorized benefit described in a formal notice.
• Appeal: a request to review or overturn an adverse benefit or eligibility decision under the process in the notice.
• Grievance: an expression of dissatisfaction about an issue other than an adverse benefit determination, such as communication or service quality.

Dentist, network, and Dental Home terms

A participating or in-network provider is enrolled for the relevant program, location, provider identity, and service circumstances. A directory result is a lead, not a guarantee that the office is accepting new patients or provides a particular procedure. Always call the exact office and verify the exact treating dentist and need.

DentaQuest uses the term Dental Home for the dental provider associated with a member in its system. Members can review Dental Home information and provider-search tools through DentaQuest. A referral is a clinical direction from one provider to another; it is different from plan authorization.

Age and program terms that change the answer

• Adult: for the standard dental summary, a Health First Colorado member age 21 or older.
• Child or youth: standard Health First Colorado members ages 0–20 use pediatric dental and EPSDT protections, without the standard annual dollar maximum.
• EPSDT: Early and Periodic Screening, Diagnostic and Treatment, the federal Medicaid child benefit that can support medically necessary care beyond listed frequency limits through the proper request process.
• Cover All Coloradans: a distinct Colorado coverage pathway. Starting July 1, 2026, enrolled CAC children ages 0–18 have a $1,100 dental annual limit; CAC orthodontics is not covered, while enrolled pregnant and postpartum CAC members do not have that $1,100 cap.
• CHP+: Child Health Plan Plus, a separate public coverage program with its own dental rules; do not apply standard Health First Colorado rules automatically.
• Dual eligible: a person who has Medicare and some category of Medicaid; the exact Medicaid category and Medicare or Medicare Advantage dental benefits affect coordination.

Cost, disclosure, and member-rights terms

No copay means the program does not require a member copayment for a covered Health First Colorado dental service. It does not mean every proposed service is covered or that a member can never choose to purchase non-covered care. A non-covered-service disclosure is the written form a participating dental provider and member complete before the member agrees to pay for truly non-covered care.

Balance billing generally means charging a member the difference between a provider's fee and what a plan pays. Colorado policy prohibits billing a Medicaid member for covered services. Coordination of benefits determines the order in which plans process a claim; Medicaid is generally payer of last resort when other coverage exists.