Prior Authorization Process

The following table provides information about prior authorization and claims submission requirements by CDT code for Children's Medicaid Dental Services. An asterisk (*) indicates that the item should be submitted only if available. Please note, some services do not require prior authorization, but do require supporting documentation such as medical necessity rationale, x-rays, color photos, pathology reports, and tooth ID numbers with claim submission.

Prior authorization of care should be requested electronically through the MCNA Provider Portal at https://portal.mcna.net. MCNA will process prior authorization requests within three (3) business days. Within 24 hours of when the determination is made, the prior authorization approval will be available to view on the Provider Portal. For providers not utilizing the Portal, the UM staff will mail a hard copy of the prior authorization approval to both the member and the provider within three (3) business days of the determination for standard requests and within 72 hours for emergency requests. The written notice will provide information on whether the requested service was approved or denied, including the criteria used to make the decision. If the prior authorization request is denied, the adverse determination notice will include information on how the member can request more information or file an appeal. Within three (3) business days of the provider referral to MCNA for review, but no later than the 10th business day after date the prior authorization was received, MCNA will make a final decision on the request.

Incomplete Prior Authorization Requests

MCNA is unable to process prior authorizations with missing essential information. Essential information includes: member name, member number or Medicaid number, member date of birth, requesting provider name, requesting provider's National Provider Identifier (NPI), service requested — Current Dental Terminology (CDT), rendering provider's name, and rendering provider's NPI. If a prior authorization is submitted with missing essential information, that request will be returned to the office submitting a request with a letter describing the essential information that is missing.

If the prior authorization request is incomplete (missing, incorrect or illegible documentation, illegible photographs, etc.), MCNA will notify the provider (via phone call if possible) and member no later than three (3) days after receiving it to request the missing or incomplete information. While MCNA is waiting for the requested information, the prior authorization request will be assigned a "pending" status. MCNA must receive the necessary information to complete the prior authorization request within 10 business days of the request's original submission. Upon receipt of the documentation, the prior authorization request will be removed from pending status and processed according to required time frames. If MCNA does not receive the requested information by the end of the 3rd business day (and the PA will be denied), the PA will be referred to a clinician for review with all information received with the request no later than the 7th business day after the PA was received. If MCNA receives the information after the tenth business day, UM staff will duplicate the request and send it through the review process.

Approved Prior Authorization Requests

Approved prior authorization requests are valid for one year from the date of approval. Both the member and provider will receive notification of which services were approved, as well as the expiration date of the authorization for the approved services. If orthodontic treatment does not begin within the valid one-year period, the provider must submit a new prior authorization request for approval. All approvals for services are assigned a unique authorization number, which must be submitted with the claim after services are rendered.

Prior Authorization Annual Review Report

The Prior Authorization Annual Review Report provides the history of all changes after September 1, 2019, for the reporting period.

More Information

Faxed prior authorization requests are accepted at 1-954-628-3331. MCNA will not return x-rays, periodontal charting, or other related documents. Please submit duplicate sets of these documents when required to be submitted with a prior authorization request.

Please review the MCNA Texas Provider Manual at https://manuals.mcna.net/texas for additional information by CDT code including frequency limitations and other specifications. Providers may contact the Provider Hotline Monday through Friday, from 7am through 7pm, at 1-855-776-6262 with requests for assistance with the prior authorization process. Members may contact the Member Hotline Monday through Friday, from 7am through 7pm, at 1-855-691-6262 to inquire about the status of prior authorization requests and for assistance understanding the prior authorization process.