MCNA Dental
Dental Details  •  Monthly Provider Newsletter
Texas Edition  •  May 2019
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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.