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EXECUTIVE SUMMARYconsistency with the contract definitions used by the Department. HSAG further recommends adding thedefinitions of “grievance,” “appeal,” and “adverse benefit determination” to the member handbook.Summary of Required ActionsHSAG found that many sections of DentaQuest’s welcome letter and member handbook were in thecorrect font size; however, the toll-free and Teletype/Telecommunications Device for the Deaf(TTY/TDD) customer service numbers in the welcome letter and the member handbook require a taglinewritten in large font. The benefits section of the handbook was written in a smaller font than required.DentaQuest must correct the tagline and font sizes in the member handbook and welcome letter.While DentaQuest’s Member Communications Distribution policy included information aboutelectronic materials availability in paper form, an incorrect time frame was listed (seven business days)and should be corrected, and members must be informed of the paper document availability and timeframe. DentaQuest must develop a mechanism to notify members that electronic information isavailable in paper form without charge upon request and is provided within five business days.Although DentaQuest has a policy regarding the 15-day member notification of provider terminations,there was no evidence available to indicate a process for doing so was in place. DentaQuest mustestablish a mechanism to inform members of provider termination within 15 days of the terminationnotice.While DentaQuest included a list of member rights in the member handbook, the list did not contain allof the required language. DentaQuest must ensure all of the required member rights are listed in themember handbook and ensure the member rights listed in the handbook and the member rightsaccessible through the Dental Program Rights and Responsibilities link on the website are consistent.The member handbook did not include a statement regarding member liability for the cost of continuedbenefits during the appeal process (if the appeal decision is adverse to the member) and lacked completeinformation regarding the requirements and time frames for filing a grievance or appeal. The memberhandbook’s section about appeals referenced claims appeals only. DentaQuest must add to the memberhandbook a statement that if benefits continue during the appeal or State fair hearing (SFH) process, themember may be required to pay the cost of services while the appeal or SFH is pending if the finaldecision is adverse to the member. In addition, DentaQuest must include complete information in themember handbook regarding the requirements and time frames for filing grievances and appeals.DentaQuest is also required to modify the member handbook language to clarify that the appeal processis not limited to denied claims.Although DentaQuest included information in the member handbook about seeking emergencyservices, it did not include a statement that prior authorization is not required for emergency services orthe fact that the member has the right to use any hospital or other setting for an emergency. DentaQuestmust revise member handbook language to inform the member that prior authorization is not requiredfor emergency services, and that the member has the right to seek services from any dental or emergencyprovider to obtain emergency care if needed.DentaQuest FY 2020–2021 Site Review ReportState of ColoradoPage 1-4DentaQuest CO2020-21 PAHP SiteRev F1 0321

EXECUTIVE SUMMARYDentaQuest’s member handbook did not include information regarding how and where to accessbenefits available under the State plan but not covered under the CHP contract, a specific reference forthe toll-free number for medical management or other units providing services directly to members, orinformation on how to report suspected fraud or abuse. DentaQuest must add information to themember handbook regarding how and where to access information about other healthcare services thatare available under the State plan, but not covered under the CHP managed care contract, such as a linkto the Department of Health Care Policy and Financing website section containing other types of benefitinformation. DentaQuest must also add information to the member handbook instructing members howto report suspected fraud or abuse and add the telephone number to contact medical management andany other departments that provide services for members.Standard VI—Grievance and Appeal SystemsSummary of Strengths and Findings as Evidence of ComplianceDentaQuest outlined its organizational structure for managing grievances and appeals, and described adedicated department located in Milwaukee, Wisconsin, that processes both grievances and appeals.DentaQuest assigned staff members to particular states to increase their understanding of state-specifictimelines and requirements. DentaQuest also cross-trained staff members so they were able to processboth grievances and appeals. DentaQuest processed all complaints as grievances unless a service denialwas involved; denied services were processed as appeals.DentaQuest updated policies, procedures, and member communications to address Colorado-specifictimelines and to correct federal definitions through work on a CAP during calendar year (CY) 2020,based on Department and HSAG feedback and direction from the previous FY 2019–2020 complianceaudit.DentaQuest used a data system to document grievance and appeal information, which included notes,calls, due dates, and correspondence from members as well as DentaQuest staff members. Grievanceaudit results demonstrated that all grievance acknowledgment letters reviewed were sent within twoworking days, and that all resolution letters were easy to understand. Both the grievance and appealresolution letters included the required content.HSAG identified one record in which DentaQuest reviewed a standard appeal request to determine if anexpedited appeal was necessary based on the member’s report of pain. DentaQuest staff membersreported that as part of their procedure, the report of pain triggered further evaluation to determine if anexpedited appeal process was appropriate to meet the member’s needs.Summary of Findings Resulting in Opportunities for ImprovementWhile policies and procedures reflected the accurate Colorado timelines for grievances and appealacknowledgement and resolutions, and DentaQuest staff members reported that training had occurredduring the review period, there were isolated instances of appeal resolutions that were out of complianceDentaQuest FY 2020–2021 Site Review ReportState of ColoradoPage 1-5DentaQuest CO2020-21 PAHP SiteRev F1 0321

EXECUTIVE SUMMARYfor timeliness after the reported date of complaint, grievance, and appeal (CGA) training. HSAGrecommends ongoing periodic training on Colorado-specific timelines and/or enhanced auditing ofColorado records during the next FY.While DentaQuest staff members accurately considered complaints to be the same as grievances, sincesome documents used the term “complaint” and others, “grievance,” HSAG recommends defining bothterms and selecting one to use throughout member documents to avoid confusion.While member and provider documents addressed members’ rights to file grievances and appeals,HSAG recommends that DentaQuest clarify in both member and provider materials that, with themember’s written consent, a provider may file a grievance, a DentaQuest-level appeal, and may requestan SFH on behalf of a member. HSAG also recommends adding additional detail in the memberhandbook to inform members that there is no deadline for filing grievances and that grievances andappeals may be filed verbally or in writing.Some required language was included in the base content of the appeal policy that was not found in thecorresponding section of the Colorado-specific exhibit of the policy. The Colorado-specific exhibit wasdepicted to “replace” the corresponding section of the base policy. HSAG recommends that DentaQuestclarify when the base content of the policies prevail and when the Colorado-specific section of thepolicies prevail.While DentaQuest’s appeal policy did not specifically state that appeals will be resolved asexpeditiously as the member’s health condition requires (i.e., if needed prior to the required timeline),HSAG found through record review that DentaQuest had an effective process to meet this requirement.HSAG recommends that DentaQuest articulate this process in policy.DentaQuest’s appeals and grievances policies accurately described the process for DentaQuest torequest an extension of resolution time frames and send written notice to the member. Both policiesincluded language stating that the notice would inform the member of the right to “contact the stateentity if they disagree with the extension invoked by DentaQuest.” While members should be informedof their right to request a grievance with DentaQuest regarding the extension, HSAG recommends thatDentaQuest remove language to contact the state entity from the policy and the appeal and grievanceextension template letters (if applicable) as the State of Colorado has no such process.Summary of Required ActionsDuring the grievance record reviews, HSAG found that three grievance resolution letters to memberswere sent more than 15 working days following the receipt of the grievance. DentaQuest must developa mechanism to ensure that all grievance resolution letters are sent within 15 working days following thereceipt of the grievance.While DentaQuest’s policies and procedures and internal training documents accurately reflected thetwo-working-day time frame for acknowledging appeals in writing, there were two appeal recordsreviewed that did not contain evidence that an acknowledgement was sent in writing within the twoDentaQuest FY 2020–2021 Site Review ReportState of ColoradoPage 1-6DentaQuest CO2020-21 PAHP SiteRev F1 0321

EXECUTIVE SUMMARYworking-day time frame. DentaQuest must develop a mechanism to ensure that all appeals areacknowledged in writing within two working days of the receipt of the appeal.DentaQuest’s policy accurately addressed the expedited resolution process and described content of thenotice to members if DentaQuest denies expedition; however, the policy did not include therequirement that the notice to deny expedition will include the member’s right to file a grievance if he orshe disagrees with the decision to deny expedition. DentaQuest submitted a revised expedited reviewdenial template letter that contained the required information within corrective action documents in2020. DentaQuest must revise its Member Appeals policy to include the requirement that the notice to amember denying an expedited review of an appeal will inform the member that he or she has the right tofile a grievance if he or she disagrees with the decision to deny expedition.DentaQuest’s policies and internal training documents included the correct time frames andrequirements for appeal resolution; however, during the appeal record review, HSAG found that fiveappeal records did not contain evidence that a resolution letter was sent to the member within therequired 10-working-day time frame. DentaQuest must develop a mechanism to ensure that all appealresolution letters are sent within the required 10-working-day time frame.DentaQuest’s Member Appeals policy as well as member and provider informational materialsincorrectly stated that members may request an SFH within 120 days from the notice of adverse ofbenefit determination (NABD). While DentaQuest’s revised appeal resolution letter template accuratelystated the time frame from “this” notice, HSAG recommends that DentaQuest clarify that the timeframe is from the notice of appeal resolution. DentaQuest must revise the policy/procedure, memberhandbook, and provider manual to clarify that the time frame is calculated from the notice of appealresolution.While DentaQuest’s policies, procedures, and member and provider informational materials addressedthe members’ rights to continue previously authorized services during an appeal and/or an SFH, thetimelines and requirements were outdated and did not reflect the federal regulation changes effectiveMay 2016. DentaQuest must ensure that policies, procedures, and member and provider materials makeit clear that: Members have the right to continue services during an appeal, and again during the SFH only if theservices were previously approved; part of a current course of treatment; and DentaQuest isproposing to terminate, reduce, or suspend the services prior to the end of the authorization period(via a 10-day advanced NABD).The member must request continuation of the services during the appeal within 10 days followingthe NABD (or before the intended effective date), but members have 60 calendar days to file theappeal.If a member has continued services during the appeal, he or she may request to continue servicesduring the SFH if the request for the continuation and the SFH are both made within 10 calendardays following the DentaQuest appeal resolution letter date.DentaQuest FY 2020–2021 Site Review ReportState of ColoradoPage 1-7DentaQuest CO2020-21 PAHP SiteRev F1 0321

EXECUTIVE SUMMARYWhile DentaQuest’s policies, procedures, and member and provider informational materials addressedthe duration of continued services during an SFH, the timelines were outdated and did not reflect thefederal regulation changes effective May 2016. DentaQuest must ensure that policies, procedures, andmember and provider materials make it clear that: If a member has continued services during the appeal, they will continue until one of the followingoccurs:– The member withdraws the appeal, or– The effective date of the termination, suspension, or reduction of the services occurs, and the memberhas not requested an SFH and has not requested continued services during the hearing process.If a member has continued services during the SFH, the services will continue until one of thefollowing occurs:– The member withdraws the SFH, or– An SFH officer issues a hearing decision adverse to the member.While DentaQuest had policies and procedures and a system designed to maintain documentation ofgrievances and appeals, HSAG found several instances during the review of appeal records thatcontained incorrect dates and inconsistent or confusing documentation. DentaQuest must ensure thatgrievance and appeal records are accurately maintained.DentaQuest’s ORM addressed grievances and appeals; however, the content was somewhat unclear asto whether members were consistently included as parties to the appeal and was missing some pertinentinformation about the time frames and requirements related to member grievances and appeals.DentaQuest must ensure that providers are notified at the time of contracting (through the ORM orother means) about the member grievance and appeal system and that the information is accurate, andmust clarify or include the following: Providers, with written consent, may file a grievance, an appeal, and may request an SFH on behalfof the member.Peer-to-peer reconsiderations must occur prior to the member receiving an NABD, otherwise theappeal process must be conducted with members being parities to the appeal.Members or their representatives may appeal pre-service as well as claims denials.Appeals must be resolved within 10 business days following the receipt of the appeal (not fromwhen documents are received) unless an extension is requested in writing that meets the contentrequirements.Grievances and appeals may be filed orally or in writing.SFHs must be requested within 120 days from the date of the notice of appeal resolution unless themember has received continued services during the appeal and is requesting continued servicesduring the SFH, in which case the SFH and the services must be requested within 10 days followingthe notice of appeal resolution.Information about requesting expedited DentaQuest-level appeals.DentaQuest FY 2020–2021 Site Review ReportState of ColoradoPage 1-8DentaQuest CO2020-21 PAHP SiteRev F1 0321

EXECUTIVE SUMMARYStandard VII—Provider Participation and Program IntegritySummary of Strengths and Findings as Evidence of ComplianceThe Network Relations team for the West/Midwest region consisted of five staff members who handledreporting and provider issues. This team was the main point of contact for providers, in addition to someadditional support provided through the contracting team, credentialing team, self-service supportthrough the Web portal, and DentaQuest’s customer service team for more general questions. Thesoftware system, Intelex, was used to monitor contract execution and the Credentialing team usedVerifPoint for initial credentialing and recredentialing, including initial and ongoing disclosure ofownership monitoring. Staff members reported that single case agreements were used very rarely, asrural and frontier dentists could often perform specialty work when needed. Additionally

Fiscal Year 2020–2021 Site Review Report . for DentaQuest March 2021 . 1. This report was produced by Health Services Advisory Group, Inc., for the