DentaQuest Customer Service — Practical, Expert Guide

Overview of DentaQuest customer service model

DentaQuest is a national dental benefits administrator and oral health services company that primarily manages public and private dental programs. Customer service is purpose-built around three stakeholder groups: members (patients), contracted providers (dentists and clinics), and state/plan partners (Medicaid/Medicare programs and commercial employers). The operational priorities are rapid access to care, transparent claims adjudication, and a documented appeals and grievance process that meets federal and state regulatory timelines.

When engaging with DentaQuest customer service, expect centralized intake (phone and online), digital self-service options, and case management for complex clinical or eligibility issues. The company publishes member and provider guides on its website (https://www.dentaquest.com) that specify plan benefits, prior authorization rules, billing codes, and timeframes for claims and appeals.

Primary contact channels and recommended first steps

Members should first consult the back of their member ID card for an exact phone number and plan-specific service hours. In most cases, DentaQuest supports: telephone Customer Service (local toll-free number printed on the ID), secure member portal access, email contact forms, and fax for documents. For non-urgent questions, the portal typically allows secure message exchange and claim status checks 24/7; telephone hours are often business days 8:00–5:00 local time but vary by state and contract.

If you do not have a member card, use DentaQuest’s main website (https://www.dentaquest.com) and the “Contact Us” page to locate state- or plan-specific information. For urgent clinical problems (uncontrolled bleeding, severe infection, facial swelling), seek immediate clinical care or call emergency services—benefit coverage questions can be handled afterwards.

Claims processing: timelines, documentation, and common denials

Typical claims workflows: electronic claims are adjudicated faster (often within 5–14 business days if “clean”), while paper claims and corrected claims can take 30–45 days. Providers should submit ADA dental claim forms (CMS 1500 or proprietary electronic 837D) with CDT procedure codes, tooth/quad notations, and supporting radiographs or narratives for complex services. Common denial reasons include missing prior authorization, non-covered service per plan, incorrect patient eligibility, and coding or billing errors.

To expedite resolution, include the patient’s member ID, date(s) of service, provider NPI, taxonomy, and itemized billed amounts. If a claim is denied, the explanation of benefits (EOB) or provider remittance advice will specify the denial reason and the steps for appeal. Providers typically have 60–180 days to file an appeal, depending on the contract and state rules; members usually have a similar window for filing grievances or appeals—always verify the deadline on the EOB or plan materials.

Appeals and grievances: practical steps and timelines

Start an appeal by submitting a written request with supporting clinical documentation, a copy of the original EOB/denial, and a clear statement of why the decision should be reversed (clinical necessity, incorrect coding, eligibility evidence). For expedited or “urgent” reviews (e.g., imminent risk to oral or overall health), request an expedited appeal—plans are typically required to respond more quickly (often within 72 hours) if the member’s health would be jeopardized by waiting.

If the internal appeal is denied, members and providers may escalate to an external review or state-level review board depending on the plan type (commercial vs. Medicaid) and the state’s external review process. Contact information for state departments of insurance and state Medicaid offices is available at each state government website and at the Centers for Medicare & Medicaid Services (https://www.cms.gov) for federal guidance.

Provider support and operational guidance

Providers contracting with DentaQuest should register for the provider portal immediately after credentialing; the portal offers real-time eligibility checks, fee schedules, prior authorization submissions, and batch claim status. Typical credentialing timelines range from 30 to 90 days depending on completeness of documentation and the state credentialing requirements.

Reimbursement rates and fee schedules differ by state contract and plan product. For accurate fee information, request a current fee schedule through the provider portal or your DentaQuest provider relations rep. Keep three items current on file: NPI/Taxonomy, W-9 or IRS equivalent, and up-to-date state license and malpractice documentation to avoid delays in payment.

What to have ready when contacting customer service

• Member documents: member ID number, full patient name and date of birth, and the date(s) of service in question.
• Provider documents: NPI, tax ID, billed CPT/CDT codes, itemized charges, copies of radiographs or clinical notes, prior authorization numbers, and an EOB or remittance advice when disputing a claim.
• Administrative: a written summary of the issue, dates and names of prior contacts, and copies of any appeals or grievance forms already submitted.

Escalation path and external resources

If initial customer service contacts do not resolve the problem, escalate to a supervisor and request a documented case number. If unresolved after internal appeals, escalate externally: for Medicaid-related disputes contact your state Medicaid office; for commercial plan issues contact your state department of insurance; for Medicare-related dental supplemental issues consult CMS resources. Keep detailed logs of all interactions including dates, times, names, and outcomes.

• Key web resources: DentaQuest main site — https://www.dentaquest.com; CMS — https://www.cms.gov; State insurance department directories (via your state government portal).
• If you need legal or regulatory guidance, consider consulting a healthcare attorney experienced in payer disputes or contacting state consumer protection offices that handle health plan complaints.

Final practical tips from a professional

Document everything and use the provider portal whenever possible. Electronic submissions reduce processing time and create an auditable trail. For members, ask your dentist to confirm eligibility and benefits before major procedures and obtain prior authorizations where required. For providers, submit panoramic or bitewing radiographs digitally with authorization requests to reduce back-and-forth.

Follow-up persistently but professionally: call to confirm receipt of appeals or supporting documents, reference the case number, and, if a case becomes time-sensitive, request an expedited review citing clinical necessity. These steps materially improve resolution speed and outcomes in most DentaQuest customer service interactions.

What company is DentaQuest?

WELLESLEY, Mass., Oct. 30, 2024 /PRNewswire/ — DentaQuest, part of Sun Life U.S., today announced it recently was awarded dental managed care (DMC) contracts by the California Department of Health Care Services (DHCS), through its subsidiary, California Dental Network.

Does DentaQuest cover tooth implants?

Our balanced plan between cost and coverage provides coverage for the important preventive and diagnostic dental services along with coverage for restorative services like: Checkups. Cleanings. Dental Implants.

How to change provider DentaQuest?

Use the Find a Dentist tool to search for dentists. Click the View Details button to learn more about a provider. To choose a new Main Dentist or Dental Home, click on the Set as Main Dentist button. Then follow the instructions to complete the change.

Does Medicaid come with DentaQuest?

DentaQuest Selected To Administer Dental Benefits for California’s Medicaid DMC Program.

How do I contact DentaQuest customer service?

Contact Us

1. Member Services. For the fastest service, call the telephone number listed on the back of your Member ID card.
2. General Member Services. 888-278-7310.
3. Dental Care Plus Group Member Services. 800-367-9466.
4. Hearing Impaired Line. 800-466-7566.

Who bought out DentaQuest?

Sun Life Financial Inc.
Sun Life Financial Inc. (TSX: SLF) (NYSE: SLF), through its U.S. business, announced today the completion of its acquisition of DentaQuest, the second-largest dental benefits provider in the U.S. by membership.