We received an email from a dentist with some very useful advice regarding denied treatment by dental MCOs (managed care organization). He specifically mentions MCNA.
I just wanted to pass on the name of a resource that I recently found who might be needed for many dentists who frequently feel legitimate treatment is denied. She appears to be helpful. As many dentists know MCNA denies appropriate treatments on occasion and down codes some procedures. According to the state provider handbook they are not allowed to do that. I believe if more dentists used Jami as a resource to complain that MCNA would cease using this tactic.
In the 2016 Medicaid Provider procedures manual: Section 1.10 in item 9 it references MCO’s and Persons Providing Services or Items Through Managed Care. Here are the two paragraphs of concern.
a) Failing, as an MCO, or an association, group or individual health-care provider furnishing services through an MCO, to provide to recipient enrollee a health-care benefit, service or item that the organization is required to provide under its contract with an operating agency;
b) Failing, as an MCO or an association, group or individual health-care provider furnishing services through an MCO, to provide to an individual a health-care benefit, service or item that the organization is required to provide by state or federal law, regulation or program rule;
Here is the contact and email for her:
Medicaid/CHIP Division, Health and Human Services Commission |4900 N. Lamar Blvd | Austin, TX 78751
Office: (512) 707-6096| email@example.com