MCNA Dental
Dental Details  •  Monthly Provider Newsletter
Texas Edition  •  May 2019
Corporate Website
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Texas Provider Hotline
1-855-776-6262
Corporate Headquarters
Managed Care of North America
200 West Cypress Creek Road, #500
Fort Lauderdale, Florida 33309
 
Using a Patient Responsibility Form
Using a Patient Responsibility Form

A patient responsibility form is a tool for use when an MCNA member's treatment plan requires the provision of services that are not covered by Medicaid and MCNA. It should also be used for elective procedures that are not medically necessary. The form will help you ensure that such treatment is adequately documented in the member's dental record after discussion with the member, or his or her parent or responsible party. To meet the documentation requirements for non-covered services, the form should clearly include the prices of all services and the signature of the member, parent, or responsible party.

MCNA Updates
Using a Patient Responsibility Form

A patient responsibility form is a tool for use when an MCNA member's treatment plan requires the provision of services that are not covered by Medicaid and MCNA. It should also be used for elective procedures that are not medically necessary. The form will help you ensure that such treatment is adequately documented in the member's dental record after discussion with the member, or his or her parent or responsible party. To meet the documentation requirements for non-covered services, the form should clearly include the prices of all services and the signature of the member, parent, or responsible party.

Guidelines for X-rays
Guidelines for X-rays

X-rays are invaluable as supporting documentation for submissions like claims and pre-authorization requests. To ensure that MCNA is able to use the x-rays you submit for their intended purpose, they must meet the following minimum requirements:

  • Must be of diagnostic quality
  • Must be labeled with the member's name
  • Must be labeled with the date x-rays were taken
  • All x-rays must be labeled as Right or Left

Submitting an x-ray that does not meet the requirements listed above may delay the adjudication of a claim or the approval of a pre-authorization request.

If you have a question about the requirements for submitting x-rays to MCNA, please call our Provider Hotline at 1-855-776-6262 (8 a.m. to 7 p.m., Central Time, Monday through Friday).

MCNA Updates
Guidelines for X-rays

X-rays are invaluable as supporting documentation for submissions like claims and pre-authorization requests. To ensure that MCNA is able to use the x-rays you submit for their intended purpose, they must meet the following minimum requirements:

  • Must be of diagnostic quality
  • Must be labeled with the member's name
  • Must be labeled with the date x-rays were taken
  • All x-rays must be labeled as Right or Left

Submitting an x-ray that does not meet the requirements listed above may delay the adjudication of a claim or the approval of a pre-authorization request.

If you have a question about the requirements for submitting x-rays to MCNA, please call our Provider Hotline at 1-855-776-6262 (8 a.m. to 7 p.m., Central Time, Monday through Friday).