MCNA maintains a Utilization Management (UM) Program that incorporates Utilization Review Criteria and Guidelines based on the needs of our members and requirements set in place by the Medicaid program. These evidence-based guidelines are used by our team of Clinical Reviewers, which is made up of fully licensed dentists with appropriate expertise, to review requests for services and determine whether a service is a medically necessary covered benefit and delivered in a consistent manner with established criteria and standards.

Generally, medically necessary services are those healthcare services that are delivered in accordance with generally accepted, evidence-based medical standards, or are considered by most dentists (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care. To be considered medically necessary, services must meet specific requirements defined by the Medicaid program.

You can see the full definition of medical necessity in MCNA's Provider Manual, which is always available to download from our Provider Portal or website. To learn more about MCNA's comprehensive UM Program, please call MCNA's Provider Hotline at 1-855-776-6262 (8 a.m. to 7 p.m., Central Time, Monday through Friday).