We have received numerous emails asking, “What can we do about DentaQuest’s [name your problem]?” Beyond quitting, we need a new adage. Yes, “the squeaky wheel gets the grease,” but a broken wheel needs more than grease because DentaQuest is apparently broken.
Look at all the articles we have published:
- Sun Life Blames “Overutilization” for U.S. Dental Income Drop While DentaQuest Squeezes Texas Dentists
- As DentaQuest Tightens the Noose on Medicaid Providers in Texas, Sun Life’s Share Price Hits Highest Ever
- DentaQuest Denying Substitute Dentist Requests to Cover Vacations, Sick Days or Emergency Situations
- A Medicaid Dentist Asks “Is it Time to Give DentaQuest the Boot?”
- DentaQuest limits dental Medicaid network in Texas
- Foreign-Owned DentaQuest Limits Access to Dental Care for 79% of Medicaid Children in Texas
- DentaQuest Stops Paying for Some Two Surface Fillings in Texas
- Sun Life completes acquisition of DentaQuest
- DentaQuest-led 3-Year Rule Outrages Medicaid Dentists
- Seniors & Patients with Disabilities Lose Out as DentaQuest Takes Over Medicaid Waiver Coverage in Webb County
- DentaQuest Dinged $1.5 Million by OIG
- Dentist Quits Texas Medicaid in Disgust Over MCNA and DentaQuest
- Dental Providers Riled Up About DentaQuest Capitation Payment Plan
HHSC is supposed to enforce contract standards for Medicaid DMOs
The truth is that DentaQuest and the other DMOs work for the state under a contract with HHSC. HHSC Medicaid and CHIP Services has its own contract management and procurement arm under Deputy Executive Commissioner James Ramirez. This agency monitors DMO performance, along with many other Medicaid contracts.
It is up to HHSC to fix this problem.
But, apparently, you have to be squeaky before HHSC will notice or stop ignoring that the wheel is broken. The more providers, the better, must speak up; otherwise, the problem will be ignored.
HHSC Dental Services Contract holds DMOs accountable
The Dental Services Contract for Texas Medicaid was amended for the 17th time and took effect September 1, 2025. The entire contract is available online here.
Here are some important excerpts:
2.3.8 ACCESS TO CARE
All Medically Necessary Covered Dental Services must be available to Dental Members on a timely basis, in accordance with appropriate dental guidelines, and consistent with generally accepted practice parameters, and the requirements in the Contract. The Dental Contractor must ensure that all Dental Members have access to a choice of Providers for all Medically Necessary Covered Dental Services. If the Dental Contractor is unable to meet this standard, the Dental Contractor must request an exception from HHSC…Providers must retain the authority to control the number of Dental Members they accept into their practice. The Dental Contractor cannot require a Provider to maintain an Open or closed panel.
The Dental Contractor must ensure that Providers offer office hours to Dental Members that are at least equal to those offered to members of the Dental Contractor’s commercial lines of business, or to Fee-for-Service participants. The Dental Contractor must ensure all Providers’ locations are accessible to Dental Members.
A Dental Contractor must provide the Medically Necessary Covered Dental Services outlined in Attachment G, “Medicaid Medically Necessary Covered Services”. If the Medically Necessary Covered Dental Services are not available through Network Providers, the Dental Contractor must, upon the request of a Provider or Dental Member, the Dental Contractor must provide a referral to an Out-of-Network (OON) provider if Medically Necessary Covered Dental Services are not available through the Provider, within the timeframes noted in Section 2.3.8.1. …
The Dental Contractor must not require the Dental Member to pay for any Medically Necessary Covered Dental Services by Providers except HHSC-specified copayments for CHIP Dental Members, where applicable.
2.3.8.1 APPOINTMENT ACCESSIBILITY
Through its Network composition and management, the Dental Contractor must ensure that the following standards for appointment accessibility are met. The standards are measured from the date of presentation or request, whichever occurs first:
1. Urgent care, including urgent specialty care, must be provided within 24 hours.
2. Therapeutic and diagnostic care must be provided within 14 Days.
3. Main Dentists must make referrals for specialty care on a timely basis, based on the urgency of the Dental Member’s oral health condition, but no later than 30 Days.
4. Preventive dental must be provided within 14 Days. Services should be offered to CHIP members in accordance with the American Academy of Pediatric Dentistry (AAPD) periodicity schedule, and to Medicaid members who are 6 months through 20 years of age, with dental checkups occurring at 6-month (180-day) intervals, and thereafter, in accordance with the AAPD periodicity schedule.
5. Non-urgent specialty care must be provided within 60 Days of authorization.
2.3.8.2 ACCESS TO NETWORK PROVIDERS
The Dental Contractor’s Network must have dental Providers in sufficient numbers, and with sufficient capacity, to provide timely access in accordance with the appointment accessibility standards in Section 2.3.8.1, “Appointment Accessibility” and in Chapter 5.28.1, Access to Network Providers Performance Standards and Specifications of the UMCM.
Counties will be designated as Metro, Micro, or Rural and as defined in ATTACHMENT N, Access Standards Map. The county designation is based on population and density parameters. Dental Members’ residences in eligibility files with HHSC will be used to assess distance and travel times. The Dental Contractor must ensure that access is consistent with 1 Tex. Admin. Code § 353.411.
HHSC will track Dental Contractor performance. HHSC will use the Dental Contractor Provider Files to run geo-mapping reports which will measure provider choice, distance and travel time from the Dental Member to the Provider. HHSC will compile the reports based on each Dental Contractor’s Network. HHSC will share identified deficiencies with the Dental Contractor.
If DentaQuest or other DMOs are not meeting these requirements, you MUST HOLD THEIR FEET TO THE FIRE! Use the complaint process!
What complaint process, you say? At one time, there was only an email address. Now there is a whole webpage explaining the process for providers to make complaints about MCO and DMO conduct with an online form is provided.
This is what the contract says about provider complaints.
2.5.2 PROVIDER COMPLAINTS AND INTERNAL DENTAL CONTRACTOR APPEALS
The following sections outline minimum requirements for the Dental Contractor’s Provider Complaints and Internal Appeals process.
2.5.2.1 PROVIDER COMPLAINTS
The Dental Contractor must develop, implement, and maintain a system for tracking and resolving all Provider Complaints. The Dental Contractor must resolve Provider Complaints within 30 Days from the date the complaint is received by the Dental Contractor. The Dental Contractor’s tracking system must include the status and final disposition of each Provider complaint. Dental Contractor must also resolve Provider Complaints received by HHSC in accordance with Chapter 3 of the UMCM. The Dental Contractor must provide information specified in 42 C.F.R. § 438.10(g)(2)(xi) about the Complaints and internal Dental Contractor Appeals system to all Providers and Subcontractors at the time they enter into a contract.
2.5.2.2 PROVIDER APPEAL OF DENTAL CONTRACTOR CLAIMS DETERMINATIONS
The Dental Contractor must develop, implement, and maintain a system for tracking and resolving all Provider Internal Appeals related to claims payment, as required by Tex. Gov’t Code § 533.005(a)(15). Within this process, the Dental Contractor must respond fully and completely to each Provider’s claims payment appeal and establish a tracking mechanism to document the status and final disposition of each Provider’s claims payment appeal. In addition, the Dental Contractor’s process must comply with the requirements of Tex. Gov’t Code § 533.005(a)(19). The Dental Contractor must contract with dentists who are OON providers [out of network providers] to resolve claims disputes related to denial on the basis of medical necessity that remain unresolved subsequent to a Provider appeal. The dentist resolving the dispute must not be an employee of the Dental Contractor’s Medicaid or CHIP business but may be an employee in the Dental Contractor’s commercial lines of business. The determination of the dentist resolving the dispute must be binding on the Dental Contractor and the Provider. The dentists resolving the dispute must be licensed in the State of Texas and hold the same specialty or a related specialty as the appealing Provider. HHSC may amend this process to include an independent review process established by HHSC for final determination on these disputes.
Providers must use the system & complain
If DentaQuest or other DMOs are not meeting these requirements, you MUST get HHSC to HOLD THEIR FEET TO THE FIRE! Use the complaint process!
What complaint process, you say?
At one time, there was only an email address – HPM_Complaints@hhsc.state.tx.us.
There is now a full webpage explaining the process for providers to file complaints about MCO and DMO conduct, along with an online form.
Have a medical necessity complaint?
Provider Appeals of Medical Necessity and Utilization Review Decision
Appeals of HHSC Office of the Inspector General (OIG) Utilization Review (UR) Decisions
Written appeals may be sent to HHSC Medical and UR Appeals at:
HHSC Medical and UR Appeals
Mail Code H-230
4601 W. Guadalupe St.
Austin, TX 78751
Questions may be e-mailed to Utilization Appeals.
For additional information on Medical and UR Appeals, refer to HHSC Medical and UR Appeals.
Have a recovery audit problem?
Appeals of Recovery Audit Contractor (RAC) decisions
Written appeals are submitted through Health Management Systems, Inc. (HMS), not directly to HHSC Medical and UR Appeals.
For submissions by mail, please use the following address:
HHSC Medical and UR Appeals
C/O HMS
5615 High Point Drive
Mail Stop #200-TX
Irving, TX 75038
or
Make submissions via HMS Provider Portal.
For more information on appeals for RAC decisions, providers can contact HMS.
Ah, what about a managed care contractor like DentaQuest?
Managed Care
Medicaid managed care providers should exhaust the complaints or grievance process with their managed care medical or dental plan before filing a complaint with HHSC. If after completing this process, the provider believes they did not receive full due process from the managed care medical or dental plan, they may file a STAR, STAR+PLUS, STAR Health, STAR Kids or managed care dental complaint or inquiry by one of the below methods:
- Using the Online Question or Complaint Form
- Emailing HPM Complaints
- Mailing the complaint of inquiry to:Texas Health and Human Services Commission
Medicaid/CHIP
Health Plan Management
Mail Code H-320
P.O. Box 85200
4900 N. Lamar
Austin, TX 78708-5200
So if DentaQuest is not following their contract or HHSC procedures, or, to our mind, if there is an excessive and ongoing problem that DentaQuest refuses to address, a complaint should be made to HHSC.
This is the complaint process:
If this doesn’t help, let us know. We have something else up our sleeve.
Providers don’t deserve this
TDMR conducted a 2012 survey of Medicaid providers at a TDA meeting on South Padre Island. 99% of the Medicaid providers who took the survey did not take Medicaid to make easy money from the government, but rather as an altruistic service to help needy children, giving them a leg up with good dental health.
We are sure all those dental providers who did or currently take Medicaid are bruised and battered by the lack of gratitude and roadblocks thrown in their way to provide this service for the state’s underprivileged children. They never thought they would need a graduate degree in government contracting and relations to work on Medicaid. Yet it seems necessary.
The Medicaid dental program needs to be managed effectively, and major dental insurance companies need to stop trampling providers.