TDMR has received and confirmed a new complaint about DentaQuest regarding the DMO’s handling of primary tooth extractions. The issue has now been independently verified by three additional dental offices, indicating it is not an isolated incident but a recurring administrative practice that directly affects patient care and provider sustainability.
Claims denied
The complaint centers on DentaQuest’s repeated denial of claims for primary teeth extractions when the insurer determines that exfoliation is “imminent.” According to the affected offices, DentaQuest routinely states that extraction is not medically necessary because the tooth is expected to fall out on its own. In practice, however, these determinations ignore the clinical reality faced by both dentists and families.
In many cases, children experience pain, discomfort, or functional issues due to loose or partially exfoliated primary teeth. Parents frequently request extraction when their child is uncomfortable, unable to eat properly, or distressed by a mobile tooth that has not yet exfoliated. Dentists are then placed in the position of having to balance patient well-being against the risk of a predictable claim denial.
No pre-authorization needed, no payment made
Complicating the issue, offices report that when they attempt to resolve it through prior authorization, DentaQuest states that no prior authorization is required for the procedure. This response effectively closes the door to pre-service review while providing no protection against post-service denial. Dentists are left with no clear path to reimbursement, even when acting in the patient’s best interest.
The result is a no-win scenario. If the dentist proceeds with the extraction, the claim is often denied on the basis of “imminent exfoliation,” forcing the practice to either write off the procedure or provide care without compensation. If the dentist declines to extract the tooth, the child continues to experience discomfort, and parents are understandably frustrated. In either case, the administrative structure ensures that DentaQuest avoids payment while shifting financial and ethical risk onto the provider.
DentaQuest most problematic DMO
Importantly, the same offices report that this problem does not occur to nearly the same extent with MCNA Dental and UnitedHealthcare Dental.
TDMR views this pattern as another example of how DentaQuest’s opaque management practices are being used to control costs without transparency or accountability. When an insurer denies claims based on criteria that cannot be challenged in advance and cannot be resolved after the fact, meaningful due process does not exist.
Providers must complain
We encourage Texas Medicaid dental providers experiencing similar denials or issues with DentaQuest to document these cases carefully, including denial language, pre-authorization correspondence, and patient impact.
Complaints should be made to Texas HHS.
Actions need to be taken
We firmly believe that DentaQuest’s behaviour warrants investigation by the Office of the Inspector General and action needs to be taken. A contractor appears to be gaming the Medicaid system, harming patients and providers in its unbridled thirst for profits for its foreign owners.
Providers should not hesitate to contact TDMR about this issue or any other DentaQuest matter via our online form or by email at info@tdmr.org.
Dentaquest has always done this. They are the worst. They shouldn’t even be handling Medicaid as they deny claims that should be paid
They do this because they want the dentist to down-code it to a D7111 instead of a D7140