Dental prior authorization checklist for Health First Colorado

When prior authorization may enter the dental process

Health First Colorado covers many dental services, but some procedures require DentaQuest to review clinical records before treatment. The current adult and child summaries identify services and categories that may be subject to clinical criteria, frequency limits, or prior authorization. The exact requirement can depend on age, program, procedure code, history, diagnosis, and proposed setting.

A referral and a prior authorization are not the same. A member may not need a referral to make a dental appointment while a proposed procedure still needs prior approval. Emergency treatment is treated differently in current summaries and should not be delayed when immediate evaluation is needed.

Information to record when the office submits

• Member name and the last four digits only of the member ID on your personal worksheet.
• Treating dentist, office address, and a reliable office contact number.
• Procedure name and code, tooth number or area, and the diagnosis or clinical reason in plain language.
• Date the request was sent, the submission method, and any reference or tracking number the office can share.
• Supporting X-rays, photographs, periodontal charting, narratives, prior treatment history, or other records requested by the plan.
• Whether the office considers the request standard or expedited and why; the plan decides whether expedited handling applies.

Questions that clarify the status

1. 1

   Was the request received and matched to the member?

   Ask for the received date and reference number. A fax confirmation or portal upload alone may not prove that the request is complete.

2. 2

   Is anything missing?

   Ask whether DentaQuest requested more clinical information and the deadline for the office to respond.

3. 3

   Has a decision been issued?

   Ask for the decision date, approved codes and units, effective dates, provider and location, and any conditions.

4. 4

   Will the office schedule now or after another check?

   The office may need to recheck active eligibility, remaining adult benefits, provider participation, and the treatment plan near the date of service.

5. 5

   Who receives the written notice?

   Confirm the member's mailing address and ask how both the member and provider will receive or access the decision.

What an approval does—and does not—settle

An approval means the plan authorized specified care under the facts reviewed. It may be limited to certain codes, units, dates, provider, location, or clinical conditions. Read the full notice and compare it with the current treatment plan before scheduling.

Final payment can still depend on eligibility on the date of service, network participation, benefit-year limits, correct coding, claim submission, coordination with other insurance, and whether the delivered care matches the authorization. Ask the dental office what it will recheck before treatment.

If the request is denied, reduced, or changed

Read the notice, identify the exact reason and deadline, and compare the decision with what the dentist requested. Ask the office whether the issue is missing documentation, a frequency rule, clinical criteria, a benefit exclusion, the adult annual limit, or another reason. A corrected or additional record may be handled differently from a formal appeal, so follow the notice.

DentaQuest's appeals page explains dental benefit appeals and grievances. Colorado's appeals page explains broader benefit and eligibility appeals. Use the contact and deadline in the notice because the correct path depends on who made the decision and what was decided.