Back in February, MCNA issued a Provider Bulletin that effective March 15 it would start reviewing restorations being redone within 36 months. The company would also start requiring prior authorizations for identical restorations and similar restorations on the same tooth.
Prior authorizations needed with evidence for work on same tooth
According to the bulletin (available below), for similar restorations on the same tooth, the prior authorization requests must include "a narrative explaining the rationale for the rework and supporting radiographs and/or photographs."
Report of prior authorization requests denied
TDMR recently received a report alleging that MCNA, despite receiving all information including radiographs showing new decay on a tooth, has denied such pre-authorization requests. It is further alleged in the report that prior authorization requests for replacement fillings have also been denied no matter the reason and evidence presented and that the dentists involved are being told that they are responsible for fixing the fillings for free.
We note that we haven't received original documents to verify these claims and do not know how many providers have been involved. But we believe it is important to bring this matter to light.
Response from MCNA
TDMR emailed MCNA executive vice-president Shannon Boggs-Turner asking about this policy and she kindly responded.
"MCNA is clinically reviewing repeat restorations. Providers must submit additional information to enable a review of the service. Both plans have taken a similar approach to deal with what is a serious clinical concern. As you know, restorations, when done properly, are anticipated to last a reasonable amount of time. MCNA is not "refusing to pay for any new or replacement fillings," we are simply requiring submission of clinical information to enable our Texas-licensed dentists to evaluate the restoration."
We have subsequently responded that "One can understand the policy if it is a replacement of the same filling. However, we were told that even with supplying radiographic evidence of new decay on a tooth, prior authorization requests are being denied and the MCNA rep is saying it is up to the dentist to do the work at no cost."
Not sure how large a problem
We do not know how general a problem this is or if it is only a few isolated instances or if it occurs with DentaQuest as well.
TDMR is open to receiving information from more providers on this issue as well as comments from the DMOs.