Coverage Determinations and Utilization Management
MCNA uses evidence-based clinical guidelines from nationally recognized authorities to make decisions in our Utilization Management (UM) program. Specifically, we review any request for the prior authorization of services to determine if members are eligible for benefits and whether the service they request is a medically necessary covered benefit under the dental plan. We also determine if the service to be delivered is consistent with established guidelines.
Our clinical reviewers, all licensed dentists, base MCNA's UM decisions on the right type of care and service to meet the needs of our members using MCNA's Utilization Criteria and Clinical Practice Guidelines. We don't pay or reward practitioners, employees or other individuals for denying coverage or care.
To enhance our network providers' experience, MCNA offers peer-to-peer consultations with our clinical reviewers. The peer-to-peer process enables our participating providers to discuss clinical determinations, including ...