MCNA Florida-V1.16

Florida Medicaid
Provider Manual
Effective Date: May 19, 2023
This Provider Manual is confidential and proprietary and may not be disclosed
to others without written permission from Managed Care of North America, Inc.
Copyright © 2023, Managed Care of North America, Inc. All Rights Reserved.
MCNA_FL-P_PM-MED[1.16] Page 1 of 97
MCNA Dental: Florida Medicaid Statewide Provider Manual
Table of Contents
Table of Contents
Table of Contents ..................................................................................................................................................... 2
1. Welcome ................................................................................................................................................................ 8
2. MCNA Contact Information ................................................................................................................................. 9

2.1. Member Services and Eligibility Verification .................................................................................................... 9
2.2. Automated Eligibility Verification ..................................................................................................................... 9
2.3. Provider Hotline ............................................................................................................................................... 9
2.4. Credentialing .................................................................................................................................................... 9
2.5. Utilization Management (Pre-Authorizations) .................................................................................................. 9
2.6. Provider Portal Helpdesk ................................................................................................................................. 9
2.7. MCNA Hotlines ................................................................................................................................................ 9
2.8. Corporate Contact Information ........................................................................................................................ 9
3. Revision History ................................................................................................................................................. 10
4. Program Overview .............................................................................................................................................. 14
5. Administration Overview ................................................................................................................................... 15

5.1. Member Enrollment ....................................................................................................................................... 15
5.2. Member ID Card ............................................................................................................................................ 15
5.3. Choosing a Primary Dental Provider ............................................................................................................. 15
5.4. Member Disenrollment ................................................................................................................................... 15
5.5. Changes in Provider and Demographic Information ..................................................................................... 15
5.6. Change in Location ........................................................................................................................................ 15
5.7. Release for Ethical Reasons ......................................................................................................................... 16
5.8. Member Dismissals from PDP Practices ....................................................................................................... 16
5.9. Termination of Dental Contract ...................................................................................................................... 16
6. Provider Responsibilities .................................................................................................................................. 18

6.1. Primary Dental Providers ............................................................................................................................... 18
6.2. First Dental Homes ........................................................................................................................................ 18
6.3. Special Needs Dental Homes ........................................................................................................................ 18
6.4. Appointments and Access to Care ................................................................................................................ 18
6.5. Healthy Behaviors Program ........................................................................................................................... 19
6.6. After Hours Emergencies............................................................................................................................... 19
6.7. Transfer of Dental Records............................................................................................................................ 19
6.8. Continuity of Care* ......................................................................................................................................... 20
6.9. Suspected Child or Adult Abuse, Neglect, or Human Trafficking .................................................................. 20
6.10. Fraud and Abuse ......................................................................................................................................... 20
6.10.1. Program Integrity................................................................................................................................... 21
6.10.2. Provider Training ................................................................................................................................... 21
6.10.3. Recovery of Overpayments .................................................................................................................. 21
6.10.4. Pre-payment Reviews ........................................................................................................................... 22
6.10.5. Payment Suspensions .......................................................................................................................... 22
6.10.6. Appeal Rights ........................................................................................................................................ 22
6.10.7. Reporting Fraud and Abuse .................................................................................................................. 22
The Department of Health and Human ................................................................................................................. 22

6.10.8. Whistleblower Protection ...................................................................................................................... 23
Table of Contents
6.11. MCNA’s Zero Tolerance Policy on Retaliation ............................................................................................ 23

6.12. Encounter Data ............................................................................................................................................ 23
6.13. Provider Compliance with Marketing and Outreach Guidelines .................................................................. 23
6.14. Health Information Portability and Accountability Act .................................................................................. 24
6.15. Advance Directives ...................................................................................................................................... 24
6.16. Medical Necessity ........................................................................................................................................ 25
6.17. Suspected Unlicensed Assisted Living Facilities (ALF) & Adult Family Care Home (AFCH) ..................... 25
6.18. Coinsurance and Copayments .................................................................................................................... 25
6.19. Laboratory Services ..................................................................................................................................... 25
7. Online Provider Portal ....................................................................................................................................... 26
8. Claims and Payments ........................................................................................................................................ 27

8.1. Paper Claim Submission via Mail .................................................................................................................. 27
8.2. Electronic Submission of Claims via MCNA’s Provider Portal ...................................................................... 27
8.3. Electronic Submission of Claims via Clearinghouse ..................................................................................... 27
8.4. Dental Provider Compensation ...................................................................................................................... 27
8.5. Prompt Payment and Explanation of Benefits/Remittance Advice ............................................................... 28
8.6. Timely Filing of Claims and Claims Handling ................................................................................................ 28
8.7. Refund Request ............................................................................................................................................. 28
8.8. Required Information ..................................................................................................................................... 28
8.8.1. National Provider Identifier (NPI) ............................................................................................................ 28
8.8.2. Other Information .................................................................................................................................... 29
8.9. Explanations of Benefits (EOBs)/Remittance Advices (RAs) ........................................................................ 29
8.10. Encounter Data Reporting ........................................................................................................................... 29
8.11. Coordination of Benefits .............................................................................................................................. 30
8.12. Payment of Non-Covered Services ............................................................................................................. 30
9. Provider Complaints and Appeals .................................................................................................................... 31

9.1. Provider Complaints ...................................................................................................................................... 31
9.1.1. Provider Complaints (Non-claims related) .............................................................................................. 31
9.1.2. Provider Complaints (Claims Related) .................................................................................................... 31
9.1.3. Unresolved Complaints ........................................................................................................................... 31
9.2. Provider Claims Appeals ............................................................................................................................... 32
10. Member Services .............................................................................................................................................. 33

10.1. Discrimination .............................................................................................................................................. 33
10.2. Confidentiality Policy .................................................................................................................................... 33
10.3. Informed Consent ........................................................................................................................................ 33
10.4. Cultural Competence ................................................................................................................................... 33
10.5. Availability and Coordination of Linguistic Services .................................................................................... 33
10.6. Role of Provider’s Bilingual Staff ................................................................................................................. 34
10.7. Patient’s Bill of Rights and Responsibilities ................................................................................................. 34
10.7.1. Summary of the Florida Patients’ Bill of Rights and Responsibilities ................................................... 34
10.8. Member Outreach ........................................................................................................................................ 35
10.9. Verification of Eligibility ................................................................................................................................ 35
10.10. Member Grievances and Appeals ............................................................................................................. 36
10.10.1. Grievance Process .............................................................................................................................. 36
10.10.2. Appeal Process ................................................................................................................................... 36
10.10.3. Urgent or Expedited Appeals .............................................................................................................. 36
10.10.4. Continuation of Benefits ...................................................................................................................... 37
Table of Contents
11. Utilization Management ................................................................................................................................... 38

11.1. Specialist Referral ........................................................................................................................................ 39
11.2. Authorizations .............................................................................................................................................. 39
11.2.1. Utilization Review Guidelines for Dental Services that Require Prior Authorization ............................ 39
11.3. Emergency Authorizations ........................................................................................................................... 39
11.4. Additional Visit and Ongoing Care Treatment Plan ..................................................................................... 40
11.5. Denials ......................................................................................................................................................... 40
11.5.1. Medical-Necessity Denials .................................................................................................................... 40
12. Treatment .......................................................................................................................................................... 41

12.1. Second Opinion ........................................................................................................................................... 41
12.2. Preventive Treatment .................................................................................................................................. 41
12.3. Participating Hospitals ................................................................................................................................. 41
12.4. Special Needs Patients................................................................................................................................ 41
12.5. Decision Making Criteria and Guidelines .................................................................................................... 42
12.6. Guidelines for Preventive Dental Care and Chronic Dental Conditions ...................................................... 42
13. Quality Improvement ........................................................................................................................................ 44

13.1. Quality Improvement Program ..................................................................................................................... 44
13.2. Your Role in Quality ..................................................................................................................................... 44
13.3. Quality Enhancement Programs (Focus Studies) ....................................................................................... 44
13.4. Quality Review of Key Performance Clinical and Service Indicators .......................................................... 45
13.5. Corrective Action ......................................................................................................................................... 45
13.6. Member Satisfaction Surveys ...................................................................................................................... 45
13.7. Provider Satisfaction Surveys ...................................................................................................................... 46
13.8. Patient Records and Chart Reviews............................................................................................................ 46
13.9. Participating Dentist Criteria ........................................................................................................................ 46
13.10. Applicability ................................................................................................................................................ 46
13.11. On-Site Office Survey ................................................................................................................................ 47
13.12. Credentialing and Re-Credentialing .......................................................................................................... 47
13.13. Credentialing Committee Appeals ............................................................................................................. 48
13.14. Practitioner Sanctioning Policy .................................................................................................................. 48
13.15. Peer Review Committee ............................................................................................................................ 49
13.16. Peer Review for Provider Disputes............................................................................................................ 49
14. Office Policies and Procedures ...................................................................................................................... 51

14.1. Office Standards .......................................................................................................................................... 51
14.2. Sterilization and Infection Control ................................................................................................................ 52
14.2.1. OSHA Requirements ............................................................................................................................ 52
14.3. Medical Emergencies .................................................................................................................................. 52
14.4. Dental Records Standards........................................................................................................................... 52
14.4.1. Confidentiality of Dental Records ......................................................................................................... 53
14.5. Access to Dental Records ........................................................................................................................... 53
15. Dental Services ................................................................................................................................................. 55

15.1. Florida Medicaid Dental Services (Children, Ages 0 to 20) ......................................................................... 55
15.2. Florida Medicaid Dental Services (Adults, Ages 21 and Over) ................................................................... 55
15.3. Emergency Services .................................................................................................................................... 55
15.4. Facility Setting Dental Treatment ................................................................................................................ 56
15.5. Telemedicine................................................................................................................................................ 56
15.6. Tele-Care Peer-to-Peer Link ....................................................................................................................... 57
Table of Contents
15.7. Oral and Maxillofacial Surgery Services ...................................................................................................... 57

15.8. Orthodontic Services ................................................................................................................................... 57
15.9. Out-of-Network Use of Non-Emergency Services ....................................................................................... 57
15.10. Caries Risk Assessment ............................................................................................................................ 57
16. Dental Guidelines ............................................................................................................................................. 58

16.1. Quick Reference Guide for ADA Codes Requiring Prior Authorization ....................................................... 58
16.2. Guidelines for X-Rays .................................................................................................................................. 59
16.2.1. Criteria ................................................................................................................................................... 59
16.3. Guidelines for Crowns ................................................................................................................................. 59
16.3.1. Criteria ................................................................................................................................................... 59
16.4. Guidelines for Crowns following Root Canal Therapy ................................................................................. 59
16.4.1. Criteria ................................................................................................................................................... 59
16.4.2. Documentation Required for Authorization ........................................................................................... 59
16.4.3. Procedure Codes .................................................................................................................................. 59
16.5. Guidelines for Core Build Up ....................................................................................................................... 60
16.5.1. Criteria ................................................................................................................................................... 60
16.5.3. Procedure Codes .................................................................................................................................. 60
16.6. Guidelines for Endodontics .......................................................................................................................... 60
16.6.1. Criteria ................................................................................................................................................... 60
16.6.2. Criteria for Retreatment of Root Canal ................................................................................................. 60
16.6.3. Criteria for Apexification ........................................................................................................................ 60
16.6.4. Criteria for Apicoectomy and Retrograde Filling ................................................................................... 61
16.6.6. Other Considerations ............................................................................................................................ 61
16.6.7. Procedure Codes .................................................................................................................................. 61
16.7. Guidelines for Periodontal Treatment .......................................................................................................... 61
16.7.1. Criteria ................................................................................................................................................... 61
16.7.2. Criteria for Gingivectomy ...................................................................................................................... 61
16.7.3. Criteria for Full Mouth Debridement ...................................................................................................... 61
16.7.5. Procedure Codes .................................................................................................................................. 62
16.8. Guidelines for Removable Prosthodontics (Complete and Partial Dentures) ............................................. 62
16.8.1. Criteria ................................................................................................................................................... 62
16.8.3. Procedure Codes .................................................................................................................................. 63
16.9. Guidelines for Oral Surgery ......................................................................................................................... 63
16.9.1. Criteria ................................................................................................................................................... 64
16.9.3. Procedure Codes .................................................................................................................................. 64
16.9.4. Code Descriptions ................................................................................................................................. 64
16.10. Guidelines for Orthodontics ....................................................................................................................... 65
16.10.1. Criteria for Orthodontics ...................................................................................................................... 65
16.10.2. Documentation Required for Authorization ......................................................................................... 65
16.11. Guidelines for Anesthesia .......................................................................................................................... 65
16.11.1. Requirements ...................................................................................................................................... 65
16.11.2. Criteria ................................................................................................................................................. 65
16.11.3. Procedure Codes ................................................................................................................................ 66
16.12. Miscellaneous Services ............................................................................................................................. 66
16.12.1. Criteria for Medical Immobilization Including Papoose Boards .......................................................... 66
Table of Contents
17. Covered Services: Children (0-20) .................................................................................................................. 67

17.1. Diagnostic Services ..................................................................................................................................... 67
17.1.1. Clinical Oral Evaluations ....................................................................................................................... 67
17.1.2. Pre-diagnostic Services ........................................................................................................................ 68
17.1.3. Caries Risk Assessment ....................................................................................................................... 68
17.1.4. Radiographs/Diagnostic Imaging (Including Interpretation) ................................................................. 68
17.1.5. Tests and Examinations ........................................................................................................................ 69
17.2. Preventive Services ..................................................................................................................................... 69
17.2.1. Dental Prophylaxis ................................................................................................................................ 69
17.2.2. Topical Fluoride Treatment (Office Procedure) .................................................................................... 69
17.2.3. Other Preventive Services .................................................................................................................... 69
17.2.4. Space Maintenance (Passive Appliances) ........................................................................................... 69
17.3. Restorative Services .................................................................................................................................... 70
17.3.1. Amalgam Restorations (Including Polishing) ........................................................................................ 70
17.3.2. Resin-Based Composite Restorations - Direct ..................................................................................... 71
17.3.3. Crowns - Single Restorations Only ....................................................................................................... 71
17.3.4. Other Restorative Services ................................................................................................................... 71
17.4. Endodontic Services .................................................................................................................................... 72
17.4.1. Pulp Capping......................................................................................................................................... 72
17.4.2. Pulpotomy ............................................................................................................................................. 72
17.4.3. Endodontic Therapy on Primary Teeth ................................................................................................. 72
17.4.4. Endodontic Therapy (Including Treatment Plan, Clinical Procedures, and Follow-up Care) ............... 72
17.4.5. Apexification/Recalcification Procedures .............................................................................................. 73
17.4.6. Apicoectomy/Periradicular Services ..................................................................................................... 73
17.5. Periodontal Services .................................................................................................................................... 73
17.5.1. Surgical Periodontal Services ............................................................................................................... 73
17.5.2. Nonsurgical Periodontal Services ......................................................................................................... 74
17.6. Prosthodontic (Removable) Services .......................................................................................................... 74
17.6.1. Complete Dentures (Including Routine Post Delivery Care) ................................................................ 74
17.6.2. Partial Dentures (Including Routine Post Delivery Care) ..................................................................... 75
17.6.3. Adjustments to Dentures ....................................................................................................................... 75
17.6.4. Repairs to Complete Dentures.............................................................................................................. 75
17.6.5. Repairs to Partial Dentures ................................................................................................................... 75
17.6.6. Denture Reline Procedures................................................................................................................... 76
17.6.7. Interim Prosthesis ................................................................................................................................. 76
17.6.8. Other Removable Prosthodontic Services ............................................................................................ 76
17.7. Prosthodontic (Fixed) Services .................................................................................................................... 77
17.7.1. Other Fixed Partial Dentures ................................................................................................................ 77
17.8.1. Oral and Maxillofacial Surgery Services ............................................................................................... 77
17.8.2. Other Surgical Procedures.................................................................................................................... 77
17.8.3. Alveoloplasty- Surgical Preparation of Ridge for Dentures .................................................................. 78
17.8.4. Surgical Incision .................................................................................................................................... 78
17.8.5. Temporomandibular Joint (TMJ) Dislocation and Management of Other TMJ Dysfunctions............... 78
17.8.6. Other Repair Procedures ...................................................................................................................... 78
17.9. Adjunctive General Services ....................................................................................................................... 79
17.9.1. Unclassified Treatment ......................................................................................................................... 79
17.9.2. Anesthesia ............................................................................................................................................ 79
17.9.3. Professional Visits ................................................................................................................................. 80
17.9.4. Miscellaneous Services ........................................................................................................................ 80
17.9.5. Teledentistry .......................................................................................................................................... 80
Table of Contents
17.10. Orthodontic Services ................................................................................................................................. 81

17.10.1. Comprehensive Orthodontic Treatment.............................................................................................. 81
17.10.2. Minor Treatment to Control Harmful Habits ........................................................................................ 82
17.10.3. Other Orthodontic Services................................................................................................................. 82
18. Covered Services: Adults (21+) ...................................................................................................................... 83

18.1. Diagnostic Services ..................................................................................................................................... 84
18.2. Prosthodontic (Removable) Services .......................................................................................................... 84
18.2.1. Complete Dentures (Including Routine Post Delivery Care) ................................................................ 84
18.2.2. Adjustments to Dentures ....................................................................................................................... 85
18.2.3. Repairs to Complete Dentures.............................................................................................................. 85
18.2.4. Repairs to Partial Dentures ................................................................................................................... 85
18.2.5. Denture Reline Procedures................................................................................................................... 85
18.3.2. Surgical Extractions .............................................................................................................................. 86
18.3.3. Other Surgical Procedures.................................................................................................................... 87
18.3.4. Alveoloplasty - Surgical Preparation of Ridge for Dentures ................................................................. 87
18.3.5. Surgical Incision .................................................................................................................................... 87
18.3.6. Other Repair Procedures ...................................................................................................................... 87
18.4. Adjunctive General Services ....................................................................................................................... 87
18.4.1. Anesthesia ............................................................................................................................................ 87
18.4.2. Professional Visits ................................................................................................................................. 88
18.4.3. Teledentistry .......................................................................................................................................... 89
18.5. Expanded Benefits for Adult Medicaid Enrollees (21+) and Pregnant Women (21+) ................................. 89
18.5.3. Preventive Services .............................................................................................................................. 89
18.5.4. Restorative Services ............................................................................................................................. 90
18.5.5. Periodontal Services ............................................................................................................................. 90
18.5.7. Adjunctive General Services ................................................................................................................. 91
18.6. Other Expanded Adult Dental Services ....................................................................................................... 91
19. Forms ................................................................................................................................................................. 92

19.1. Medicaid Orthodontic Initial Assessment Form ........................................................................................... 92
19.2. Other Forms ................................................................................................................................................. 97
MCNA Dental: Florida Medicaid Statewide Program Provider Manual
Section 1: Welcome
1. Welcome
Dear MCNA Provider:
Managed Care of North America (MCNA) would like to take this opportunity to welcome you and your staff as part
of our national network of dental providers. We are pleased that you have chosen to participate with us.
Throughout your ongoing relationship with MCNA this Provider Manual will give you useful information concerning
the MCNA plans in which you have chosen to participate.
MCNA was founded by a group of dentists with extensive backgrounds in the field of dental care and dental plan
operations. MCNA’s goal is to provide quality dental services to members and providers. MCNA recognizes the
vital role the dental office plays in a successful dental plan. The purpose of this Provider Manual is to provide you
with an explanation of MCNA's administrative policies and procedures, provisions, and the role you play as a
dentist.
When communicating with our network
providers, we make every effort to be clear For the latest version of this manual in digital form,
and concise. Our expectation is to answer please access the MCNA Provider Portal at:
questions promptly when they arise. We strive
to provide accurate and effective information
that allows you and your dental team to
http://portal.mcna.net
understand which American Dental or visit:
Association (ADA) Current Dental
Terminology (CDT) codes are covered and http://manuals.mcna.net/florida
what to expect from MCNA.
to download a PDF version directly.
MCNA may make additions, deletions, or
changes to the policies and procedures
described in this Provider Manual at any time
and will give providers at least 30 days
advance notice before implementation. As a
participating provider, your agreement requires you to comply with MCNA policies and procedures including those
contained in this manual.
If you require assistance or information that is not included within this manual, please contact our Provider Hotline
(See Section 2: MCNA Contact Information).
We will communicate changes in MCNA’s policies and procedures as well as state and federal laws to you
through the dissemination of provider bulletins.
Again, we welcome you and your staff to the growing list of MCNA providers. We look forward to a successful
relationship with you and your practice.
Sincerely,
MCNA Provider Relations Department
Section 2: MCNA Contact Information
2. MCNA Contact Information

For the quickest service, please use the direct phone and fax numbers listed below. Please note that all calls are
recorded for quality assurance purposes.
2.1. Member Services and Eligibility Verification

Member Services Representatives are available from 8am – 8pm EST, Monday – Friday, excluding national
holidays.
Member Services: 1-855-699-6262
TDD/TTY (All Plans): 1-800-955-8771
2.2. Automated Eligibility Verification

Our Automated Member Eligibility Hotline is available 24 hours a day, 7 days a week.
Main: 1-855-699-6262
2.3. Provider Hotline

Main: 1-855-698-MCNA (1-855-698-6262)
eFax: 1-954-628-3329
Email: prdepartment@mcna.net
2.4. Credentialing
Main: 1-855-698-MCNA (1-855-699-6262)
Main Fax: 1-954-628-3349
2.5. Utilization Management (Pre-Authorizations)

Main: 1-855-698-MCNA (1-855-699-6262)
eFax: 1-954-628-3331 (Not for prior authorization submissions.)
Email: um_fl_group@mcna.net (For questions and status updates only,
not for prior authorization)
2.6. Provider Portal Helpdesk

Main: 1-855-232-MCNA (1-855-232-6262)
2.7. MCNA Hotlines

Fraud, Waste, and Abuse: 1-855-FWA-MCNA (1-855-392-6262)
Compliance: 1-855-683-MCNA (1-855-683-6262)
2.8. Corporate Contact Information

When sending mail to a specific department, please address it to the attention of that department.
Mailing Address: MCNA Dental
P.O. Box 740370
Atlanta, GA 30374-0370
Main: 1-855-698-MCNA (1-855-699-6262)
Main Fax: 1-954-730-7875
Section 3: Revision History
3. Revision History
Version Date Revision Information
1.16 5/19/2023 Throughout document: Shaded covered services sections by population

type: children shaded BLUE, adults shaded GREEN, pregnant/other adult
shaded PINK
Section 2 – Updated MCNA contact information
Section 8.4 – Included language on Medicaid provider enrollment.
Section 9.2 – corrected appeal time frame language to 90 days.
Section 11.2.1 – Removed verbiage, updated approved authorization
effective days.
Section 16.1 – Updated Description
Section 16.7.5 – Updated description
Section 16.8.1 – Removed verbiage
Section 17.1.4 - Updated description
Section 17.2.4 – Added D1556, D1557, D1558
Section 17.3.3 – Updated crown verbiage
Section 17.3.4 – Updated crown verbiage
Section 17.8.1 – Updated limitation for D7140 & D7210 & D7241
Section 17.8.3 – Removed requirements for D7472
Section 17.9.2 – Updated changes to sedation limitations for D9222,
D9223, D9230, D9239, D9243
Section 17.10 – Added verbiage
Section 18.3.1 – Updated limitation for D7140
Section 18.3.2 – Updated limitation for D7210
Section 18.4.1 – Updated changes to sedation limitations for D9222,
D9223, D9230, D9239, D9243
Removed the PA requirement for the following codes in the covered
services section of each population: D2710, D2721, D2740, D2751, D2950,
D2951, D2954, D3230, D3240, D3310, D3320, D3330, D3331, D3333,
D3351, D3352, D3353, D3410, D3430, D4210, D4211, D4260, D4261,
D4341, D4342, D4346, D4355, D5511, D5512, D5520, D5730, D7140
(adult), D7220, D7230, D7240, D7250, D7260, D7261, D7280, D7283,
D7296, D7297, D7310, D7320, D7472, D7473, D7510, D7520, D7881,
D7970, D9222, D9223, D9239, D9243, D9248
1.15 12/30/2022 Updated 16.4.3 – Added D2928 description

Updated 16.7.4 – Updated CDTs
Updated 17.1.4 – Updated D0210, D0220, D0230, and D0330 limitations
Updated 17.2.2 – Updated D1354 Description
Updated 18.1.2 - Updated D0210, D0220, D0230, and D0330 limitations

Updated 18.2.3 – Updated Verbiage
Updated 18.3.2 – Updated D7241 limitations
Updated 18.5.3 – Updated D1354 Description
Updated 19.2 – Added Overpayment and Recoupment Form
1.14 10/01/2022 Updated Section 2.8 – Updated Corporate Mailing Address

Updated Section 8.1 – Updated Claims Address
Updated Section 14.4 – Updated Dental Record Standards
Updated Section 14.4 - Updated Dental Record Standards
Updated Section 16.10.2. Added additional language to requirement
Updated Section 17.1.4 - Updated language
Updated Section 17.6.2 - Update language, added additional language to
requirement.
Updated Section 18.2.2 - Updated and added additional language
Updated Section 18.5.2 – Update Language
1.13 10/2021 Updated Section 9.1.1 – Updated Provider Notification timeframe from 15
to 30 days.
Updated Section 9.1.2 – Updated Provider Notification timeframe from 15
to 30 days.
Updated Section 10.7 – Updated Patient’s Bill of Rights and
Responsibilities.
Updated Section 16.8.1 – Removed post treatment radiograph information.
Updated Section 17.10.3 – Removed arch requirement for D8703 & D8704.
Updated Section 17.3.4. – Added additional language
1.12 06/2021 Removed references to referrals throughout the manual.
Updated Section 11.1 – Removed the referral requirements and added
details regarding specialists.
Removed Section 11.1.1
Updated Section 12.6 – Updated definitions of services. Added link to
MCNA’s Clinical Practice Guidelines for Florida Medicaid.
Section 15.10 – Updated descriptors of CDT codes listed in section
Updated Section 16 – Revised descriptors of CDT codes throughout Dental
Guidelines
Updated Section 16.7.3 – Added details to criteria
Updated Section 16.7.4 – Added D4240, D4241, and D4346
Updated Section 16.8.1 – added D5213 and D5214
Updated Section 16.9.2 – Changed “Panorex” to “panoramic”
Updated Section 17 per 2021 CDT Codebook:
• Added the following CDT codes: D1355 and D2928.
• Revised descriptors for the following CDT codes: D0210, D0220,
D0230, D0240, D0250, D0251, D0270, D0272, D0274, D0330,
D0340, D0350, D1208, D1351, D1510, D1553, D1575, D2330,
D2331, D2332, D2335, D2920, D2950, D3310, D3320, D3330,

D4210, D4211, D4240, D4241, D4260, D4261, D4355, D5630,
D5730, D5731, 5740, D5741, D5750, D5751, D5760, D5761,
D7111, D7140, D7250, D7310, D7320, D8660, D8670, D9223,
D9230, D9239, D9243, D9420, and D9440.
• Updated requirements / limitations for the following CDT codes:
D2931, D7241, D7510, D7520, D7880, D7970, D7999, D8070,
D8080, and D8090.
Updated Sections 17.6.3 – 17.6.6 – Added statement “Considered inclusive
within six (6) months of seating of partial or complete dentures.” Removed
references to immediate dentures.
Updated Section 18 per 2021 CDT Codebook:
• Revised descriptors for the following CDT codes: D0210, D0220,
D0230, D0240, D0330, D5630, D5660, D5730, D5731, 5740,
D5741, D5750, D5751, D5760, D5761, D7210, D7250, D7310,
D7320.
• Updated requirements / limitations for the following CDT codes:
D5110, D5120, D7241, D0190, and D0191.
Updated Sections 18.2.3 – 18.2.6 – Added statement “Considered inclusive
within six (6) months of seating of partial or complete dentures.” Removed
references to immediate dentures.
Updated Section 18.2.3 – Removed requirement for pre-authorization for
CDT codes listed.
Updated Section 18.5 - Added verbiage "Pregnant members are eligible for
additional exams, dental screenings, x-rays, cleanings, fluoride, oral
hygiene instructions, deep cleanings, and general services that are
medically necessary."
1.11 06/2020 Page 10 - Updated Credentialing Fax Number: 954-628-3349

Page 22 - Updated link for Department of Children and Families
Page 24 - Updated link for Medicaid Fraud and Abuse Form
Page 27 - Removed last sentence in the Medical Necessity section
Page 89 - Modified description of code D5622 in the Covered Services
section
Page 85 - Updated requirements for Endodontic Therapy
1.10 03/2020 Children’s Covered Services:
• Added the following CDT codes: D1551, D1552, and D1553.
• Removed the following CDT codes: D1550 and D8692.
• Updated requirements for D5110, D5120, D5211, D5212, D5213,
D5214, D7111, D7472 and D7473.
Adult Covered Services:

• Added the following CDT codes: D8703, D8704
D5214, D7472, and D7473.
1.9 06/2019 Updated information about limitations on anesthesia services.
Updated requirements for D0145, D1330, D7472, and D7473.
1.8 05/2019 Updated requirements for anesthesia services.
Updated requirements for D9230.

Updated frequency limitation for D9920 under Children’s covered services.
1.7 05/2019 Updated Guidelines for Removable Prosthodontics (Full and Partial
Dentures).
Updated Coinsurance and Copayments section.
Changed the following in the Covered Services for Children (0-20):

• Updated descriptions for D0120, D0150, D5120, D5211, and
D5212
• Updated requirements for D1516 and D1517,
Changed the following in the Covered Services for Adults (21+):

• Updated descriptions for D5213 and D5214
1.6 03/2019 Updated Provider Compliance with Marketing and Outreach Guidelines
section.
1.5 03/2019 Updated time frames for member grievances and appeals processes.
Updated provider credentialing sources.
Updated dental records standards
Children’s Covered Services:

D8080, and D8090.
• Updated description of Pre-Diagnostic Services
• Removed D1515, and added D1516 and D1517
• Updated requirements for other restorative services.
Adult Covered Services:

• Updated requirements for D5110 and D5120
• Updated description of D5211 and D5212
1.4 12/2018 Update to time frame for continuation of care.
1.3 12/2018 Update to limitation for D0150 for adult members.
1.2 11/2018 Updates to expanded benefits for adults. Updates to pre-authorization

requirements for children. Updates to requirements for D9230.
1.1 11/2018 Corrected time frame for submission of member grievance. Corrected time
frame for decision about expedited member appeal.
1.0 11/2018 Initial version.
Section 4: Program Overview
4. Program Overview
Medicaid is funded by both the state and federal government to provide health care coverage for eligible children,
seniors, disabled adults, and pregnant women.
MCNA’s mission and values are to assure access to quality health services for Florida’s children with a focus on
families, cultural awareness, innovation, and compassion.
Section 5: Administration Overview
5. Administration Overview
5.1. Member Enrollment

Once a member is enrolled with MCNA, the member receives a welcome package which includes a Member
Handbook, Member ID Card, and Provider Directory. The member must present their ID card prior to receiving
services.
5.2. Member ID Card

MCNA will issue member ID cards for all members.
It is the responsibility of the dental office to verify member eligibility and determine if the member has other dental
or health insurance. MCNA strongly recommends the dental office require a member to present his or her ID card
and confirm the member’s eligibility with MCNA on our online Provider Portal at http://portal.mcna.net or via
phone. MCNA also advises the dental office keep a copy of the ID card in the member’s chart.
5.3. Choosing a Primary Dental Provider

MCNA believes Primary Dental Providers (PDPs) help ensure access to necessary dental care and continuity in
coordination of care. PDPs include general dentists and pediatric dentists.
5.4. Member Disenrollment

MCNA cannot disenroll members under its own initiative or request disenrollment of a member because of: a pre-
existing dental condition, adverse changes in a member’s health status, periodically missed appointments,
diminished mental capacity, health diagnosis, uncooperative or disruptive behavior resulting from the enrollee’s
special needs, an attempt to exercise rights under MCNA’s grievance system, utilization of dental services, or a
request from a PDP to have a member assigned or transferred to a different provider out of MCNA’s network.
MCNA network providers should not provide or assist members in the completion of a dismissal/transfer request
or assist choice counselors in the dismissal/transfer process of a member.
Members should be advised to contact Member Services (See Section 2: MCNA Contact Information) for
questions regarding disenrollment.
5.5. Changes in Provider and Demographic Information

Providers are required to notify MCNA’s Provider Relations department in writing at least 90 days in advance of
any changes in information regarding their practice. Such changes include:
• Address changes, including changes for satellite offices
• Additions/deletions to a group
• Changes in billing locations, telephone numbers, and tax ID numbers
Reimbursement may be affected if changes are not reported in accordance with MCNA policy.
5.6. Change in Location

Should a provider working in multiple offices discontinue working in one location, it is imperative that MCNA be
notified of any changes as soon as possible. MCNA must be advised of any changes that occur with any provider
who is participating, if a facility hires a new provider, or if a provider leaves a facility. Communication must be
clear if employment is terminated in one (1) location as well as the specific offices where employment is
continuing.
5.7. Release for Ethical Reasons

A participating provider is not required to perform any treatment or procedures that may be contrary to the
provider’s conscience, religious beliefs, or ethical principles. If such a situation arises, the provider should contact
the Provider Hotline (See Section 2: MCNA Contact Information). A Provider Services Representative will work
with the provider to review the member’s needs and transfer or refer the member to another appropriately
qualified provider for care.
5.8. Member Dismissals from PDP Practices

Primary Dental Providers (PDPs) have the right to request a member's transfer from their practice and request the
member be reassigned to a new PDP under the following circumstances:
• Incompatibility within the PDP/patient relationship
• A member’s disruptive behavior that impairs the PDP’s ability to provide services to the member or others
• Inability to meet the dental needs of the member due to member non-compliance
PDPs do not have the right to request a member’s transfer from their practice in the following situations:
• A change in a member’s health status or need for treatment
• A member’s utilization of dental services
• A member’s diminished mental capacity
• A member’s disruptive behavior that results from the member’s special health care needs unless the
behavior impairs the PDP’s ability to provide services to the member or others
Transfer requests shall not be based on the grounds of race, color, national origin, handicap, age, or gender.
To request a transfer, complete a Member Outreach Form and select “Provider requests transfer of member from
panel.” The form can be downloaded from the Provider Portal. Submit the form to MCNA by regular mail or by fax
provided on the Member Outreach Form. Requests must include provider name, provider ID number, member
name, member ID number, and the reason for the transfer request. Members are not transferred from the PDP’s
practice until all required information is received and the request is approved.
Upon receipt of the transfer request, MCNA will counsel the member and attempt to resolve the issue(s) between
the PDP and member. In the event the issue(s) cannot be resolved, MCNA will follow Medicaid protocol to
transfer the member. The member transfer will be facilitated according to Medicaid guidelines. Until the transfer is
approved by Medicaid, the PDP must continue to provide dental care to the member, barring ethical or legal
issues. The member has the right to appeal such a transfer through MCNA’s formal appeal process.
If a PDP's request does not meet the requirements stated above, the appropriate Provider Relations
Representative will contact the PDP directly to discuss the situation.
5.9. Termination of Dental Contract

Upon 90 days’ notice, MCNA may terminate a provider from the network for any misrepresentation(s) made on
his/her application. Causes for termination with a 90 day notice include, but are not limited to:
• Failure to meet participating criteria
• Failure to provide requested dental records
Causes for immediate termination include, but are not limited to:
• Fraud
• Expulsion from, discipline by, or barred from participation in any state Medicaid Program or the
Medicare Program
• Loss or suspension of the provider’s professional liability coverage
• Failure to cooperate with or abide by MCNA’s Quality Improvement Program
• Engagement in conduct injurious to MCNA’s business reputation
Providers who wish to voluntarily terminate participation with MCNA must provide MCNA with a 90-day notice of
termination in writing. The notice must be faxed, e-mailed or mailed to the Provider Relations department (See
Section 2: MCNA Contact Information) with a certified return receipt, and include the final termination date.
Section 6: Provider Responsibilities
6. Provider Responsibilities
6.1. Primary Dental Providers

MCNA providers shall provide, or arrange for coverage of, services, or consultation 24 hours per day, seven days
per week (24/7) to Medicaid-enrolled members. This coverage consists of an answering service, call forwarding,
provider call coverage, or other customary means approved by MCNA. The chosen method of 24/7 coverage
must connect the caller to someone who can render a clinical decision or reach the Primary Dental Provider
(PDP) for a clinical decision. The after-hours coverage must be accessible using the dental office’s daytime
telephone number.
Also, the PDP shall arrange for coverage of primary dental services during absences due to vacation, illness, or
other situations that render the PDP unable to provide services. Another MCNA-participating PDP must provide
coverage.
If you enter into any contracts, agreements, or subcontracts for the purposes of carrying out any aspect of the
contract between you and MCNA, they shall include assurances that the individual(s) who are signing the
contract, agreement, or subcontract are so authorized and that it includes all the requirements outlined in your
Provider Agreement with MCNA.
6.2. First Dental Homes

The First Dental Home program targets children between ages 0 and 3. The American Academy of Pediatric
Dentistry encourages parents and other care providers to help every child establish a First Dental Home by 12
months of age. By establishing a First Dental Home for infants and younger children, this program helps create an
early pattern of good oral hygiene and a series of positive experiences at the dentist’s office from a young age.
Providers who complete the First Dental Home training course are recognized with a special designation in our
provider directory and priority member assignment for children in this age group. All PDPs who treat children
under 3 years of age in the MCNA network will be eligible to participate in this program.
6.3. Special Needs Dental Homes

The Special Needs Dental Home program targets children with special health care needs who are especially
vulnerable to dental issues. The program aims to address gaps in early and regular preventive care often
experienced by children with special health care needs. Providers who are interested in participating in this
program must complete an MCNA-approved special health care needs training course. We also recognize
providers who have been granted the credential of Diplomate in Special Care Dentistry by the American Board of
Special Care Dentistry (ABSCD). Providers participating in the Special Needs Dental Home program must agree
to use MCNA’s teledentistry capability, our Tele-Care Peer-to-Peer link, which facilitates access to dental
specialist consultations by sharing radiographs, charting, and narratives through our secure, HIPAA-compliant
Provider Portal. All Special Needs Dental Home providers are given special recognition in our provider directory
and are preferred for member assignment via our Case Management Department.
6.4. Appointments and Access to Care

Providers must provide the same availability to MCNA members as is done for all other patients as stated on
page two (2) of section 2.1 in the Provider Agreement.
The Provider Agreement outlines appointment availability standards. The standards below are monitored by
MCNA as part of our Quality Improvement Program:
• Emergency Care
o Patient must have access to emergency care 24 hours day, 7 days a week to relieve pain or
prevent worsening of a condition. The dentist must be available to the member or arrange for
another participating dentist to provide services.
• Urgent Care
o Patient must be seen immediately or within 24 hours (swelling, bleeding, fever, infection).
• Routine Sick Patient Care

o Patient must be seen within one (1) week.
• Well Care Visit
o Patient must be seen within one (1) month.
• Follow-up Dental Services
o Patient must be seen within one (1) month after assessment.
Appropriate access to care is an essential part of MCNA’s Quality Improvement Program. Access to care is
monitored by the Provider Relations department. Periodically, a written inquiry or phone call may be generated by
MCNA to obtain information concerning the next available appointment.
The provider or his or her covering credentialed and participating provider must respond to a member within 30
minutes after notification of an emergency or urgent call.
6.5. Healthy Behaviors Program

MCNA recognizes that a successful Main Dental Home requires member adherence to recall visits in
accordance with the periodicity schedule. To help our network providers achieve the best results, we have
developed our Healthy Behaviors Program designed to assist your office with timely recall visit adherence
by providing them with incentives to seek preventive services and complete an oral health assessment.
Parents or guardians of MCNA members who receive an initial exam and preventive services followed by
a timely six-month recall visit with preventive services qualify to earn a $10 Amazon.com gift card per
child. To claim this reward, the parent/guardian must give MCNA their email address and cell phone
number by signing in to our Member Portal at https://member.mcna.net and completing a short form.
Parents/guardians can also earn an additional $15 Amazon.com gift card per child when they fill out an
Oral Health Assessment Form for the child and submit it to MCNA. The form may be found in the forms
section of the Member Handbook and on MCNA’s website at https://docs.mcna.net/forms/member-oha.
Adult members aged 18 and older are also eligible to earn both of these rewards for completing the steps
listed above. Full terms and conditions are available at https://www.mcnafl.net. We encourage you to
share details about MCNA’s Healthy Behaviors Program with our members upon their first visit to your
office.
6.6. After Hours Emergencies

According to American Dental Association Principles of Ethics and Code of Professional Conduct, each practice is
obligated to make reasonable arrangements for the emergency care of their patients of record. These
arrangements should cover any time outside of regular business hours (evenings, weekends, and holidays).
The provider shall provide or arrange for coverage of services, or consultation, 24 hours per day, 7 days per week
(24/7) by Medicaid-enrolled providers who will accept Medicaid reimbursement. This coverage shall consist of an
answering service, call forwarding, provider call coverage, or other customary means approved by the Agency for
Health Care Administration. The chosen method of 24/7 coverage must connect the caller to someone who can
render a clinical decision or reach the provider for a clinical decision. The after-hours coverage must be
accessible using the dental office’s daytime telephone number.
The provider shall arrange for coverage of primary dental services during absences due to vacation, illness, or
other situations that render the PDP unable to provide services. An MCNA-participating provider must provide
coverage.
6.7. Transfer of Dental Records

Please request that the member authorizes release of his or her dental records to you from practitioners who
treated the member prior to visiting your office.
If a member wishes to transfer to another participating dental office, there will be no charge to the member for the
copying of charts and/or radiographs subject to MCNA policies. All copies must be provided to the MCNA member
within five (5) days of the request.
6.8. Continuity of Care*

MCNA allows members in active treatment to continue care with their current dental provider as long as the
provider was not terminated for cause, when such care is medically necessary, through completion of treatment of
a condition for which the enrollee was receiving care at the time of the termination, or until the member selects
another treating provider. None of the above treatment(s) may exceed ninety (90) days after the termination of the
provider's contract. Except in this circumstance, a terminated provider may refuse to continue to provide care to a
member who is abusive or noncompliant.
For continued care under this section, MCNA and the terminated provider will continue to abide by the same
terms and conditions outlined in the contract prior to termination.
Continuation of Care will be allowed from previous dental insurances through Medicaid for up to 180 days for non-
orthodontic related services. Continuation of care for orthodontic related services will be covered until the
treatment has been completed. Please contact our Provider Hotline for more information.
6.9. Suspected Child or Adult Abuse, Neglect, or Human Trafficking

Cases of suspected child or adult abuse or neglect might be uncovered during examinations.
Child abuse is the infliction of injury, sexual abuse, unreasonable confinement, intimidation or punishment that
results in physical pain or injury, including mental injury. Abuse can also be an act of omission (Child Laws: FS
Chapter 39).
Adult abuse is defined as “the infliction of physical pain, mental injury or injury of an adult.” The statute describes
an adult as “(a) a person 18 years of age or older who because of mental or physical dysfunction is unable to
manage his [her] own resources or carry out the activity of daily living or protect himself [herself] from neglect or a
hazardous or abusive situation without assistance from others and who may be in need of protective services; or
(b) a person without regard to age who is the victim of abuse or neglect inflicted by a spouse” (Adult Laws: FS
Chapter 415).
If suspected cases are discovered, a report should be made immediately by telephone, fax, or online to the
Department of Children and Families at:
Telephone Hotline: (800) 962-2873
Fax: (800) 914-0004
Website: https://reportabuse.dcf.state.fl.us/
Human Trafficking is the recruitment, harboring, transporting, providing or obtaining, by any means, a person for
labor or services involving forced labor, slavery or servitude in any industry, such as forced or coerced
participation in agriculture, prostitution, manufacturing, or other industries or in domestic service or marriage
(Freedom Network, based on the federal criminal law definitions of trafficking). If you suspect human trafficking,
call the National Human Trafficking Hotline at 1-888-373-7888.
In addition to continuing education (CE) requirements for providers to complete a domestic abuse course once
every four (4) years, MCNA requires all network providers to complete an online training session annually about
abuse, neglect, exploitation and identifying victims of human trafficking. Providers may access this training
session when they log in to the MCNA Provider Portal at http://portal.mcna.net.
6.10. Fraud and Abuse

The Federal False Claims Act and the Federal Administrative Remedies for False Claims and Statements Act are
specifically incorporated into § 6032 of the Deficit Reduction Act. These Acts outline the civil penalties and
damages against anyone who knowingly submits, causes the submission, or presents a false claim to any U.S.
employee or agency for payment or approval. U.S. agency in this regard means any reimbursement made under
Medicare or Medicaid. The False Claims Acts prohibits anyone from knowingly making or using a false record or
statement to obtain approval of a claim.
“Fraud” is defined as an intentional deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to himself or some other person. It includes any act that
constitutes fraud under applicable Federal and State law.
“Abuse” is defined as provider practices that are inconsistent with sound fiscal, business, or medical practices,
and result in an unnecessary cost or that fail to meet professionally recognized standards for healthcare. It also
includes members’ practices that result in unnecessary cost to the Medicaid Program.
"Knowingly" is defined in the statute as meaning not only actual awareness that the claim is false or fraudulent,
but situations in which the person acts with his eyes shut, in deliberate ignorance of the truth or falsity of the
claim, or in reckless disregard of the truth or falsity.
The following are some examples of billing and coding issues that can constitute false claims and high-risk areas
under this Act:
• Billing for services not rendered
• Billing for services that are not medically necessary
• Billing for services that are not documented
• Up coding
• Participation in kickbacks
Penalties (in addition to amount of damages) may range from $5,500 to $11,000 per false claim, plus three (3)
times the amount of money the government is defrauded. In addition to monetary penalties, the provider may be
excluded from participation in the Medicaid or Medicare program.
6.10.1. Program Integrity

MCNA is committed to controlling fraud, waste and abuse in our state and federal dental programs. Our efforts
include monitoring, investigation, enforcement, training, and communication. MCNA monitors the appropriateness
and quality of services provided to our members and proactively seeks potential fraud and abuse using resources
such as, but not limited to, claims, utilization management, quality management, grievance, appeals and
complaints, and random chart audits.
Pursuant to Medicaid regulations, in the event of suspected fraud and/or abuse, chart audits may be conducted
without prior notice. Findings suggestive of fraud and abuse will be reported to the Medicaid Office of Program
Integrity as appropriate. Any resolution to audit findings and investigations in no way binds the State of Florida nor
precludes the State of Florida from taking further action for the circumstances that brought rise to the matter.
6.10.2. Provider Training

MCNA provides ongoing training to providers and their staff members of their responsibilities to detect, prevent
and report fraud and abuse. MCNA conducts face-to-face trainings and provides educational information for
providers regarding fraud and abuse through the provider portal and provider newsletters. Providers and offices
are responsible for ensuring they and their staff are adequately trained regarding fraud and abuse. These training
resources may be utilized for offices to train providers and staff.
6.10.3. Recovery of Overpayments

MCNA verifies services billed by dental providers by performing pre- and post-payment reviews to prevent or
recover overpayments paid to providers. An overpayment includes any amount that is not authorized to be paid
by state and federal programs whether paid as a result of inaccurate or improper claims submissions,
unacceptable practices, fraud, abuse, or a mistake. When an overpayment is identified, MCNA shall begin
payment recovery efforts. Providers will be given the opportunity to submit a refund or payment plan within 60
days after it is identified. If the provider and MCNA do not agree upon a refund or acceptable payment plan,
MCNA will pursue all remedies, including termination from participation in our network, to recover the funds.
In accordance with 42 CFR §438.608(d)(2), any network provider who determines that they have received an
overpayment from MCNA must notify us in writing of the reason for the overpayment and return the funds within
60 calendar days of the date on which the overpayment was identified.
The provider's office may return the overpayment by check, or may choose to have the amount deducted from a
future Remittance Advice (RA). Overpayment notifications and refund checks should be mailed to the following
address:
MCNA Dental
Claims Department - Attn: Recoupment and Overpayments
P.O. Box 740370
Atlanta, GA 30374-0370
If MCNA does not receive the full refund of the overpayment amount within the required time frame, the remaining
amount will be satisfied by offset of future reimbursements. Please call our Provider Hotline at 1-855-698-6262 (8
a.m. to 8 p.m., Eastern Time, Monday through Friday).
6.10.4. Pre-payment Reviews

MCNA has implemented a pre-payment review process to safeguard against the delivery of unnecessary
services, and to ensure payments are appropriate.
As part of the prepayment review process, providers will be required to submit supporting documentation with each
claim for all services bill that are under scope of the review. The documentation will be used to determine if services
billed were medically necessary and billed in accordance with MCNA’s policies and guidelines, and State and
Federal regulations. Non-compliant providers are subject to administrative sanctions, up to and including corrective
action plans, suspension or termination of participation in the MCNA network.
6.10.5. Payment Suspensions

If MCNA has credible evidence of fraud, willful misrepresentation, or abuse under the requirements set forth by
state and federal dental programs, MCNA shall have the right to impose claims payment suspensions on a
provider and a facility. An allegation of fraud, willful misrepresentation, or abuse is considered credible once all
allegations, facts, and evidence pertaining to that specific case have been carefully reviewed by MCNA, revealing
indicia of reliability. The suspension of payment action will be temporary and will not continue if MCNA determines
that there is insufficient evidence of fraud, willful misrepresentation, or abuse by the provider.
6.10.6. Appeal Rights

MCNA allows any provider or person against whom it enforces payment holds or recoupment requests a right to
appeal this action by requesting an informal review. A request for an informal review must be received in writing
not later than 10 days after the date you receive the notice of the payment hold, and not later than 40 days after
the date you receive the recoupment notice. Appeals should be mailed to MCNA’s corporate headquarters
address (See Section 2: MCNA Contact Information), “Attn: Corporate Investigations.”
Along with your appeal, you may submit any documentary evidence that addresses whether the payment hold is
warranted and any related issues. MCNA will consider your appeal and your evidence carefully. You will be
contacted after that consideration is completed and a decision about your case is made.
6.10.7. Reporting Fraud and Abuse

Providers are also required to cooperate with the investigation of suspected fraud and abuse by MCNA’s
Compliance department, state and federal government agencies, and local law enforcement agencies. If you
suspect fraud and abuse by MCNA, a member, or a provider, it is your responsibility to report this immediately by
calling one of the telephone numbers listed below:
MCNA Dental Fraud Hotline: (855) 392-6262
Agency for Health Care Administration: (888) 419-3456
Florida Attorney General Medicaid Hotline: (866) 966-7226
The Department of Health and Human
Services Office of the Inspector General (OIG): (800) 447-8477

You can report fraud and abuse online by completing a Medicaid Fraud and Abuse Complaint Form, which is
available at: https://www.myflfamilies.com/service-programs/abuse-hotline/. Confidentiality will be maintained for
the suspect person or entity and the person reporting, and all rights afforded to both providers and members will
be reserved and enforced during the investigation process.
You may report suspected cases of fraud and abuse anonymously. You may also report confidentially without fear
of retaliation.
If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or
other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Reward
Program (toll-free 1-866-966-7226 or 1-850-414-3990). The reward may be up to 25 percent (25%) of the amount
recovered, or a maximum of $500,000 per case (Florida Statutes Chapter 409.9203). You can talk to the Attorney
General’s Office about keeping your identity confidential and protected.
If you have any questions, please call us (See Section 2: MCNA Contact Information).
6.10.8. Whistleblower Protection

Federal False Claims Act (31 U.S.C. § 3730(h))
The False Claims Act (FCA) provides protection to qui tam relators who are discharged, demoted, suspended,
threatened, harassed, or in any other manner discriminated against in the terms and conditions of their
employment as a result of their furtherance of an action under the FCA (31 U.S.C. § 3730(h)). Remedies include
reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two (2)
times the amount of any back pay, interest on any back pay, and compensation for any special damages
sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.
6.11. MCNA’s Zero Tolerance Policy on Retaliation

MCNA recognizes and supports the importance of establishing open lines of communication regarding reporting
“suspected” violations of regulatory compliance requirements including “potential” instances of fraud, waste and
abuse as these relate to inappropriate uses of federal and/or state government funds earmarked for Medicare
and/or Medicaid enrollees.
MCNA upholds a ZERO tolerance policy for retaliation against employees, officers, directors, managers,
contractors, or enrollees who report “suspected” and/or “potential” misconduct or abuse. MCNA, as part of
informing these stakeholders, reminds employees and subcontractors that they are protected from retaliation
under 32 U.S.C. 3730(h) for False Claims Act complaints, as well as other applicable anti-retaliation protections.
6.12. Encounter Data

MCNA is required by contract to collect encounter data from our providers. We are authorized to take whatever
steps are necessary to ensure that the provider is recognized by the state Medicaid program, including its choice
counseling/enrollment broker contractor(s) as a participating provider of MCNA and that the provider’s submission
of encounter data is accepted by the Florida Medicaid Management Information System (MMIS) and/or the state’s
encounter data.
6.13. Provider Compliance with Marketing and Outreach Guidelines

All providers will be responsible for compliance with the following guidelines:
• Providers cannot orally or in writing compare benefits or provider networks among dental plans, other
than to confirm whether they participate in a dental network.
• Providers may co-sponsor events, such as health fairs, and advertise with MCNA in indirect ways, such
as television, radio, posters, fliers, and print advertisements
• Providers shall not furnish lists of their Medicaid patients to a dental plan with which they contract, or any
other entity, nor can providers furnish their MCNA membership lists to another dental plan or assist with
Medicaid enrollment
• Providers may distribute information about non-specific healthcare services and the provision of health,
welfare, and social services by the State of Florida or local communities as long as any inquiries from
prospective enrollees are referred to the Agency for Health Care Administration’s (AHCA’s) choice
counselor/enrollment broker
• Providers may display MCNA-specific materials in their own offices
When a provider becomes affiliated with a Prepaid Dental Health Plan, the provider must comply with the
following requirements:
• Providers may announce a new or continuing affiliation with a Prepaid Dental Health Plan through general
advertising (e.g., radio, television, websites).
• Providers may make new affiliation announcements within the first 30 days of the new provider
agreement.
• Providers may make one (1) announcement to patients of a new affiliation that names only the new
Prepaid Dental Health Plan when such announcement is conveyed through direct mail, email, or phone.
• Additional direct mail and/or email communications from providers to their patients regarding affiliations
must include a list of all Prepaid Dental Health Plans with which the provider has agreements.
To ensure compliance with AHCA’s marketing guidelines, MCNA will monitor complaints from members,
providers, event sponsors and participants, and other agencies for outreach and marketing violations. MCNA will
issue corrective actions such as counseling and additional training for any provider who violates the requirements.
Depending on the severity of the violation, disciplinary actions including suspension or termination of the Provider
Agreement may be enforced.
6.14. Health Information Portability and Accountability Act

Providers are responsible for complying with all HIPAA privacy and security provisions. Member information shall
be treated as confidential so as to comply with all federal and state laws and regulations regarding the
confidentiality of patient records. Providers have the responsibility to safeguard the privacy of any health
information that identifies a particular member in accordance with 42 CFR, Part 431, Subpart F and agree that the
information from, or copies of, medical records may be released only to authorized individuals. Providers shall
ensure that unauthorized individuals do not gain access to or alter patient records. Providers shall release original
medical records only in accordance with federal or state laws, court orders, or subpoenas.
For more information about HIPAA, visit the HHS website at https://www.cms.gov/Regulations-and-
Guidance/Administrative-Simplification/HIPAA-ACA/index.
6.15. Advance Directives

The Patient Self-Determination Act (PSDA), under Florida Law, requires that every able adult (18 years or older)
must be given the right to make decisions about their medical care. The law recognizes the right of a competent
adult to make an advance directive that:
• Instructs his or her dentist to provide, withhold, or withdraw life-prolonging procedures
• Allows the patient the right to participate in and direct their own healthcare decisions
• Designates another individual to make treatment decisions if the person becomes unable to make his or
her own decisions
• Indicates the desire to make an anatomical donation after death
Members can make an advance directive by completing a Living Will or a Designation of Health Care Surrogate
form.
Providers can never discriminate against members based on whether or not they have an advance directive.
Thus, providers are encouraged to discuss advance directives with members and document in the dental record
that education was provided. If the member has an advance directive, the provider should include a copy of it in
the member’s dental record.
6.16. Medical Necessity

Services as defined under FS 409.9131 that meet the following conditions: “Medical necessity” or “medically
necessary” means any goods or services necessary to palliate the effects of a terminal condition or to prevent,
diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or
suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally
accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the
final arbiter of medical necessity. In making determinations of medical necessity, the agency must, to the
maximum extent possible, use a physician in active practice, either employed by or under contract with the
agency, of the same specialty or subspecialty as the physician under review. Such determination must be based
upon the information available at the time the goods or services were provided.
6.17. Suspected Unlicensed Assisted Living Facilities (ALF) & Adult Family Care Home
(AFCH)
Providers are required to report any suspected unlicensed activities for Assisted Living Facilities (ALF) and Adult
Family Care Home (AFCH) to The Agency of Health Care Administration. If you suspect unlicensed facility
activity, please have the following information to report:
• Facility address, phone number, and name if available
• Owner/operator name and phone number if available
• Description of activity and number of residents (if known) leading to report of suspected unlicensed
activity
• Your contact information (name, address, phone number, and email) for additional information if needed.
If you provide contact information, results of the investigation will be provided.
Please call or mail your complaint to:
Agency for Health Care Administration Complaint Hotline
2727 Mahan Drive, Mail Stop #49
Tallahassee, Florida 32308
Phone (Toll Free): 888-419-3456
6.18. Coinsurance and Copayments

Adult members may be responsible for a $3.00 copayment, per visit, per day for non-emergency dental services
provided in a federally qualified health center.
6.19. Laboratory Services

All services, provided directly or indirectly under the plan, shall be performed within the borders of the United
States and its territories and protectorates. This includes but is not limited to dental laboratory services.
Section 7: Online Provider Portal
7. Online Provider Portal

MCNA offers all of our providers an online Provider Portal that allows you to:
• Verify member eligibility
• View a roster of your members
• View a history of your activity with MCNA
• Submit claims, pre-authorizations
• View and print Remittance Advices (RAs)
• Manage a daily appointment book
• Download your Provider Manual
• Much more!
The Provider Portal is a great all-in-one tool, and we recommend all of our providers take advantage of its
features. You can quickly and easily create an account at http://portal.mcna.net to access the Provider Portal.
For more information about using the online Provider Portal, visit http://guides.mcna.net/portal to download a
comprehensive User Guide.
Section 8: Claims and Payments
8. Claims and Payments

Claims for services provided to MCNA members should be submitted to MCNA.
Claims may be submitted in three (3) ways:
1. On paper via mail
2. Electronically via MCNA’s online Provider Portal
3. Electronically via a clearinghouse
Note: Faxed claims will not be accepted.
8.1. Paper Claim Submission via Mail

Paper claims must be submitted on the ADA 2012 (or newer) claim form. This form may be downloaded and
printed from our Provider Portal after you log in. Paper claims may be submitted by mail to:
MCNA Dental
PO Box 23920
Oakland Park, FL 33307
It is important to affix sufficient postage when mailing in bulk. MCNA does not accept postage due mail.
Insufficient postage will result in the mail being returned to sender and the processing of your claim will be
delayed. MCNA will not accept handwritten claims.
8.2. Electronic Submission of Claims via MCNA’s Provider Portal

MCNA’s online Provider Portal, http://portal.mcna.net, allows participating providers free claims submission and
tracking of all MCNA claims.
Please print a copy of the claim and eligibility form for your records.
FastAttach (NEA) may be used for electronic claims requiring the submission of an x-ray. For those not able to
electronically attach x-rays, please send a copy of the MCNA electronic claim or the 2012 ADA claim form along
with the x-ray(s) to MCNA’s corporate headquarters address (See Section 2: MCNA Contact Information), “Attn:
Claims Department.”
8.3. Electronic Submission of Claims via Clearinghouse

MCNA providers may submit electronic claims through clearinghouses that transmit claims to Change Healthcare.
MCNA’s Payor ID code is 65030.
8.4. Dental Provider Compensation

For additional information, please call our Provider Hotline (See Section 2: MCNA Contact Information). Claims
will be denied if the member is not eligible for coverage on the date of service. MCNA is prohibited from issuing
payment to any provider not enrolled with Medicaid on the date of service. For more information related to
Medicaid registration, please contact AHCA.
8.5. Prompt Payment and Explanation of Benefits/Remittance Advice

MCNA’s claims processing policies, payments, procedures, and guidelines follow applicable state and federal
requirements. In order for MCNA to process a “clean claim,” the claim must be able to be processed without
obtaining additional information from the provider of the service or from a third party. It does not include a claim
from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity,
pursuant to 42 CFR 447.45.
8.6. Timely Filing of Claims and Claims Handling

If your claim is not received within the specified time from the date of service it may be denied for late submission.
A clean claim is a claim that has no material defect, impropriety, lack of any required substantiating
documentation, or special circumstance(s), such as, but not limited to, coordination of benefits, pre-existing
conditions, subrogation, or suspected fraud, that prevents timely adjudication of the claim.
• Florida-specific definition of a clean claim: A claim that can be processed without obtaining additional
information from the provider of the service or from a third party. It does not include a claim from a
provider who is under investigation for fraud or abuse, or a claim under review for medical necessity,
pursuant to 42 CFR 447.45.
An electronic clean claim will be paid or denied within 15 calendar days. A paper clean claim will be paid or
denied within 20 calendar days.
Claims are considered to be filed timely if submitted within 365 days from the date of service.
8.7. Refund Request

MCNA strives to pay claims accurately the first time; however, when payment errors occur, MCNA needs your
cooperation in correcting the error and recovering any overpayment. If you identify a refund due to MCNA, please
mail your refund along with the Overpayment and Recoupment Form downloadable in the Provider Portal.
If MCNA identifies an overpayment, a notification of overpayment will be sent following the provider’s receipt of
the overpayment. The notification will explain the reason for the refund.
A provider office may dispute MCNA’s claim of overpayment and has the right to appeal the overpayment request.
All appeals must be received no later than 40 days from the date of Notification of Overpayment. The appeal must
be in writing, explain why the provider’s office believes recoupment is not warranted, and must contain any
supporting documentation to be considered for review.
Provider Overpayment and Recoupment Forms, refund checks, and overpayment request appeals may be faxed
or mailed to MCNA’s corporate headquarters (See Section 2: MCNA Contact Information), “Attn: Claims
Department – Refunds.”
8.8. Required Information

All claims should be submitted to MCNA on a 2012 ADA (or newer) claim form. The claim form must include the
following information to be considered clean and complete:
8.8.1. National Provider Identifier (NPI)

NPI numbers are now required. All claims must contain the provider’s NPI (Type 1) in box 54 to be considered a
clean claim. If you are a part of a group practice, include the group’s NPI (Type 2) in box 49 on all claims. If you
are in practice by yourself, include your NPI (Type 1) in box 49 on all claims. This is a state and federal
requirement.
You can apply for a NPI one (1) of two (2) ways:
• Online at https://nppes.cms.hhs.gov.
• By completing a paper application. You can download a copy through https://nppes.cms.hhs.gov, or call
(800) 465-3203 to request a copy.
8.8.2. Other Information

All claims should be submitted to MCNA on a 2012 ADA (or newer) claim form. The claim form must also include
the following information to be considered clean and complete:
• Member name
• Member identification number
• Member and/or guardian signature (or Signature on File)
• Member date of birth
• Description of services rendered
• Provider NPI number
• Provider name, signature, office address, office ID number, phone number, and state license number
• Proper CDT coding with tooth numbers, surfaces, quadrants, and arch, when applicable
• Full mouth series x-ray, bitewings, and/or periapical x-rays, when needed
Note: Claims will be denied if the member is not eligible on the date of service.
8.9. Explanations of Benefits (EOBs)/Remittance Advices (RAs)

Explanations of Benefits (EOBs)/Remittance Advices (RAs) will be available online for all offices. For offices
receiving Electronic Funds Transfer (EFT) payments, the EOB will only be available online. For offices receiving a
paper check, the EOB will be included in the envelope. Offices that receive EFT payments have the option to
request that a paper EOB be sent at the time of payment. Should you have any questions, please contact
MCNA’s Provider Hotline (See Section 2: MCNA Contact Information).
8.10. Encounter Data Reporting

MCNA requires its contracted providers to submit encounter data on a regular basis. MCNA is required to submit
encounter data for all adjudicated claims. The data is used for many purposes, such as reporting to the Medicaid
Management Information System (MMIS), rate setting and risk adjustment, MCNA's Quality Improvement
Program, HEDIS reporting, and analyzing provider reimbursement for both fee-for-service (FFS) and capitated
services provided.
According to MCNA policy, providers must report all member encounters by claims submission either
electronically or by mail to MCNA. The following are some tips for encounter submissions:
• Even though capitated services are not reimbursed on a fee-for-service basis, it is important to include
exact service charges on the claim as you would when billing any other carrier. Encounters must be
submitted even when MCNA is not the primary payer.
• If you use an automated billing or practice management system, please confirm that the system allows for
the submission of claims with zero (0) dollar balances to facilitate the transmission of both capitated and
secondary claims.
If you are a capitated provider or do not submit fee-for-service claims, you must submit encounter data to MCNA
on a monthly basis. Encounter data can be transmitted via HIPAA ASC X12N 837D file format or in Microsoft
Excel file format. If you choose to submit in Microsoft Excel file format, the minimum information required is:
• Subscriber ID
• Subscriber first name, last name, and middle initial
• Subscriber date of birth
• Subscriber SSN
• MCNA assigned office ID
• Office name
• Office address
• Office telephone number
• Rendering provider first name, last name, and middle initial
• Rendering provider NPI
• Rendering provider state license number
• Plan name
• Encounter date
• CDT ADA code of service rendered
• Applicable tooth letter or number
• Applicable surface letter
• Service quantity
• Service bill amount
For further information, please contact MCNA's Electronic Data Interchange (EDI) group via email at
edi@mcna.net.
8.11. Coordination of Benefits

It is the provider’s responsibility to find out if members have other dental insurance coverage. MCNA must be
advised of any other insurance that may have liability for services. We need to determine the order of benefits
before we can process the claim. When other insurance coverage exists and MCNA is the secondary insurer, a
copy of the primary insurance Explanation of Benefits (EOB) must be submitted with all claims for the member.
These claims may be filed electronically if an electronic copy of the EOB is attached. MCNA will deem a claim
paid in full when the primary insurance payment meets or exceeds MCNA’s reimbursement rates.
8.12. Payment of Non-Covered Services

MCNA will not pay a provider for non-covered services. According to the MCNA Provider Agreement, (Section 2.2
of the Medicaid Addendum) providers are obligated to hold members, the Plan, MCNA, and the State of Florida
harmless for payment of non-covered dental services.
A provider may bill the member for non-covered services only with a signed letter of understanding from the
member prior to rendering the service. The letter of understanding from the member must include the following:
• A statement that the member has agreed in writing that they are financially responsible for the described
services.
• A complete description of the dental services to be rendered and an explanation of all options available.
The member (or the person who is financially responsible for the member) must acknowledge their
understanding of this information after explanation from the provider and indicate agreement to be
financially responsible. The member (or the person who is financially responsible) must acknowledge that
they agree to be responsible of their own free will and have not been coerced. An attestation of this shall
be included on the signature page.
• Indication that the provider can only charge the maximum of their usual and customary fees less 25%.
However, any medically necessary service needed for enrollees under the age of 21 years when the service is not
listed in the service-specific Florida Medicaid Coverage and Limitations Handbook, Florida Medicaid Coverage
Policy, or the associated Florida Medicaid fee schedule, or is not a covered service of the plan may be submitted
for review with narrative, x-rays, and prior authorization.
Section 9: Provider Complaints and Appeals
9. Provider Complaints and Appeals
9.1. Provider Complaints

Providers may call to discuss any issues or concerns (See Section 2: MCNA Contact Information). The Provider
Relations department addresses provider complaints regarding topics such as dissatisfaction with administration,
claims practices, provision of services, or the MCNA contract. Both contracted and non-contracted providers may
submit a complaint, verbally or in writing, to MCNA. A Provider Relations representative will review and resolve
any complaint received from a provider. Medicaid providers may submit complaints on behalf of Medicaid
recipients. Provider complaints may be reported to the Provider Relations department in writing or verbally within
45 calendar days for issues that are not about claims; and 90 days from the date of final determination from
MCNA to file a written complaint for claims issues. Complaints may be sent by mail to MCNA’s corporate
headquarters address (See Section 2: MCNA Contact Information), “Attn: Provider Relations.”
9.1.1. Provider Complaints (Non-claims related)

Provider complaints may be reported to the Provider Relations department in writing within 45 calendar days for
issues that are not about claims. Complaints may be sent by mail to MCNA’s corporate headquarters address
(See Section 2: MCNA Contact Information), “Attn: Provider Relations.”
Upon receipt of the complaint, a Provider Relations Representative will notify the provider that the complaint has
been received and the expected date of resolution within three (3) business days. The Provider Relations
Representative investigates and resolves the complaint within 90 days for other related complaints from the time
the complaint is received. If a complaint remains unresolved after 30 days of receipt, the Provider Relations
Representative will notify the provider why and provide written notice every 30 days thereafter. Upon resolution of
the complaint, the Provider Relations Department informs the provider verbally about the outcome of the
investigation and sends the provider the resolution in writing within three (3) business days. All provider
complaints concerning claims issues are processed and resolved in accordance with s. 641.3155, F.S. and s.
408.7057, F.S.
9.1.2. Provider Complaints (Claims Related)

Provider complaints may be reported to the Provider Relations department in writing within 90 days from the date
of final determination from MCNA. Complaints may be sent by mail to MCNA’s corporate headquarters address
(See Section 2: MCNA Contact Information), “Attn: Provider Relations.”
Upon receipt of the complaint, a Provider Relations Representative will notify the provider that the complaint has
been received and the expected date of resolution within three (3) business days. The Provider Relations
Representative investigates and resolves the complaint within 60 days for claims complaints from the time the
complaint is received. If a complaint remains unresolved after 30 days of receipt, the Provider Relations
Representative will notify the provider why and provide written notice every 30 days thereafter. Upon resolution of
the complaint, the Provider Relations Department informs the provider verbally about the outcome of the
investigation and sends the provider the resolution in writing within three (3) business days. All provider
complaints concerning claims issues are processed and resolved in accordance with s. 641.3155, F.S. and s.
408.7057, F.S.
9.1.3. Unresolved Complaints

In the event that MCNA and the provider are unable to find a resolution, MCNA will utilize Maximus, the Agency
contracted dispute resolution vendor, as described in s. 408.7057, for managing, addressing and resolving
provider complaints related to claims issues. MCNA and the provider will be required to submit all documentation
within fifteen (15) days after receipt of a request for documentation in support of the claim dispute. This process
shall comply with s. 641.3155, F.S.
If a decision made by Maximus is in favor of the provider, MCNA will ensure that all recommendations are
adhered to. All claims pertaining to the unresolved complaint will be reprocessed and paid to the provider.
Section 9: Provider Complaints and Appeals
9.2. Provider Claims Appeals

MCNA’s providers may request a formal review of our decision to deny a claim based on medical-necessity by
filing an appeal. Appeals must be filed in writing within 90 calendar days from the date of the initial denial
determination. You may download the appeal form from MCNA’s Provider Portal if you would like to mail your
appeal. In lieu of the appeal form, a letter may be submitted along with the provider’s signature on the provider’s
letterhead that contains the member’s name, sufficient information to reasonably identify the claim or claims being
appealed, such as date of service, provider name, procedure, claim number, and a statement that the request is
for an appeal. The appeal request date is the date that MCNA’s mailroom received the appeal or the date you
submitted the appeal on the Provider Portal. Please be sure to include a copy of the EOB/RA identifying the claim
and any supporting documentation such as narratives, radiographs, or models as appropriate to the review.
MCNA will take into account all information submitted by the provider without regard to whether such information
was submitted or considered in the initial consideration of the claim(s) in question.
For medical-necessity determinations, a dental provider who holds an active current license and who is a clinical
peer and is in the same profession or similar specialty that typically manages the condition or treatment and who
was not involved in the initial denial and is not a subordinate of the individual who made the initial determination
will review all claims appeals regarding medical-necessity denials. The provider may also request that the
reviewing provider be of like or similar specialty. MCNA will notify the provider in writing of the appeal decision
within 30 calendar days from our receipt of the appeal. The appeal decision is final, and, at that point, the provider
will have exhausted all appeal options with MCNA. All provider appeals and supporting documentation should be
submitted to MCNA’s corporate headquarters address (See Section 2: MCNA Contact Information), “Attn:
Grievances and Appeals Department – Provider Appeals.”
If you have any questions about the appeal process, please contact MCNA’s Provider Relations Department (See
Section 2: MCNA Contact Information).
Section 10: Member Services
10. Member Services
10.1. Discrimination
A provider must not differentiate, distinguish, or discriminate in the treatment of any member because of the
member’s race, color, national origin, ancestry, religion, health status, sex, marital status, age, political beliefs, or
source of payment.
10.2. Confidentiality Policy

MCNA follows HIPAA requirements and requires its contracted providers to also adhere to HIPAA requirements.
Provider agreements require that all providers maintain patient information in a current, detailed, organized and
comprehensive manner and in accordance with the customary dental practices, applicable state and federal laws,
and accreditation standards. Providers must have policies and procedures to implement these confidentiality
requirements. In addition to complying with customary dental practices, applicable state and federal law, and
accreditation standards, these policies and procedures should include, but are not limited to, protection of patient
confidentiality under the following circumstances:
1. The release of information at the request of a member or in response to a legal request for information
2. The storage of and restricted access to dental records in secured files
3. The education of employees regarding confidentiality of dental records and patient information
10.3. Informed Consent

Providers must understand and comply with applicable legal requirements, as well as adhere to the policies
regarding informed consent from their patients of the dental community in which they practice. The provider must
give the member adequate information and be reasonably sure the member has understood it before proceeding
with treatment. Consent documents should be written and signed by the member prior to treatment.
10.4. Cultural Competence

We want to ensure that MCNA meets the communication needs of members with limited English proficiency.
MCNA facilitates access to dental services for non-English speaking members. MCNA’s member population is
culturally and linguistically diverse and recognizes that this diversity sometimes serves as a barrier to members
and it affects the member's willingness to access all available services. Title VI of the Civil Rights Act specifically
requires that managed care organizations provide assistance to persons with limited English proficiency, where a
significant number of the eligible population is affected.
MCNA has adopted the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health
Care recommendations (minorityhealth.hhs.gov) as a guideline to developing the Cultural Competency Program.
MCNA encourages contracted providers to address the delivery of care and services to members with diverse
values, beliefs, and backgrounds in a way that varies according to their ethnicity, race, language, and abilities.
We want to ensure that MCNA meets the communication needs of members with limited English proficiency.
MCNA’s Quality Improvement team monitors and evaluates the level of cultural competency through dental
services provided by our network of dentists. MCNA encourages employees and providers to share and utilize
their own cultural diversity to enhance our program and the services provided to our members.
10.5. Availability and Coordination of Linguistic Services

MCNA does not require members to provide their own interpreter when utilizing the services available to them
through MCNA. MCNA ensures that dental care services are presented in a culturally and linguistically
appropriate manner utilizing the member’s primary language:
• Interpreter services are available through MCNA at no charge when accessing dental care.
• Member refusal of interpreter services must be documented.
• Friends or family members are only used as an interpreter when specifically requested by the member.
Minors are not to be used as an interpreter.
• Member may request face-to-face or telephone interpreter services to discuss complex dental information
and treatment options.
• Informative documents must be available and translated into threshold languages, including braille, sign
language, and tactile sign language.
• Members have a right to file a complaint or grievance if linguistic needs are not met.
• Each provider office must be aware of and have a translator card explaining how to access services.
• Dental provider offices are informed of the availability of the TTY phone number for the hearing impaired
(See Section 2: MCNA Contact Information).
10.6. Role of Provider’s Bilingual Staff

The role of the bilingual staff in provider offices is to assist members to access and receive dental services and to
understand the instructions they receive from the person speaking to them. If the member speaks a language not
spoken by a staff person, the telephone interpreter service should be utilized.
It is the responsibility of the provider’s office to notify MCNA in writing within 30 days of a change in the linguistic
capacity of the office affecting the provider’s ability to provide health services.
To get a free copy of the MCNA Cultural Competency Program, contact MCNA’s Provider Hotline (See Section 2:
MCNA Contact Information).
10.7. Patient’s Bill of Rights and Responsibilities

Providers are required to prominently display in the reception area of the provider’s office: the Agency’s statewide
Consumer Call Center’s phone number (888-419-3456) including hours of operation pursuant to section
641.511(8), Florida Statutes, and a copy of the summary of Florida Patient’s Bill of Rights and Responsibilities, in
accordance with Section 381.026, Florida Statutes. A complete copy of the Florida Patient’s Bill of Rights and
Responsibilities shall be available, upon request by a member, at each provider’s office(s).
10.7.1. Summary of the Florida Patients’ Bill of Rights and Responsibilities

A patient has the right to:
1. Be treated with courtesy and respect
2. Always have your dignity and privacy respected
3. Receive a quick and useful response to your questions and requests
4. Know who is providing medical services and who is responsible for your care
5. Know what member services are available, including whether an interpreter is available if you do not
speak English
6. Know what rules and laws apply to your conduct
7. Be given information about your diagnosis, the treatment you need, and openly discuss choices of
treatments, risks, and how these treatments will help you
8. Participate in making choices with your provider about your dental care, including the right to say no to
any treatment, except as otherwise provided by law
9. Be given full information about other ways to help pay for your health care
10. Know if the provider or facility accepts the Medicare assignment rate
11. To be told prior to getting a service how much it may cost you
12. Get a copy of a bill and have the charges explained to you
13. Get medical treatment or special help for people with disabilities, regardless of race, national origin,
religion, handicap, or source of payment
14. Receive treatment for any health emergency that will get worse if you do not get treatment
15. Know if medical treatment is for experimental research and to say yes or no to participating in such
research
16. Make a complaint when your rights are not respected
17. Ask for another doctor when you do not agree with your doctor (second medical opinion)
18. Get a copy of your medical record and ask to have information added or corrected in your record, if
needed
19. Have your medical records kept private and shared only when required by law or with your approval
20. To file a grievance about any matter other than a plan’s decision about your services
21. To appeal a plan’s decision about your services
22. Receive services from a provider that is not part of our plan (out-of-network) if we cannot find a provider
for you that is part of our plan
23. Speak freely about your health care and concerns without any bad results
24. Freely exercise your rights without the Plan or its network providers treating you badly
25. Get care without fear of any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation
26. Request and receive a copy of your medical records and ask that they be amended or corrected.
A patient has the responsibility to:
1. Give accurate information about your health to your plan and providers
2. Tell your provider about unexpected changes in your health condition
3. Talk to your provider to understand your dental problems and agree on a treatment plan. Make sure you
understand a course of action and what is expected of you
4. Listen to your provider, follow instructions for care, and ask questions
5. Keep your appointments, and notify your provider if you will not be able to keep an appointment
6. Be responsible for your actions if treatment is refused or if you do not follow the health care provider's
instructions
7. Make sure payment is made for non-covered services you receive
8. Follow health care facility conduct rules and regulations
9. Treat health care staff and case manager with respect
10. Tell us if you have problems with any health care staff
11. Use the emergency room only for real emergencies
12. Notify your case manager if you have a change in information (address, phone number, etc.)
13. Have a plan for emergencies and access this plan if necessary for your safety
14. Report fraud, abuse and overpayment
10.8. Member Outreach

MCNA’s Member Outreach activities help members to appropriately access services within MCNA and better
understand their dental benefits. MCNA’s providers can request assistance from Member Services to provide
additional education to members who need further explanation on such issues as the importance of keeping
scheduled appointments, and utilizing the emergency room appropriately.
Providers can refer non-compliant members for additional education regarding their benefits and services by
completing a Member Outreach Form, which can be downloaded from the Provider Portal. An MCNA
representative will contact the member and follow up with the provider at the provider’s request.
10.9. Verification of Eligibility

Member eligibility varies by month. Therefore, each participating provider is responsible for verifying member
eligibility with MCNA before providing services.
Eligibility can be verified by:
• Calling MCNA Member Services (See Section 2: MCNA Contact Information),
• Faxing MCNA at least 24 hours in advance (See Section 2: MCNA Contact Information) (please allow at
least 24 hours for a faxed response), or
• Electronically by logging on to MCNA’s online Provider Portal (http://portal.mcna.net) and using the
subscriber eligibility feature.
Note: Due to possible eligibility status changes, the information provided does not guarantee payment.
10.10. Member Grievances and Appeals

Members have the right to file a grievance or an appeal. A provider may file a grievance or request an appeal on
the member’s behalf with the member’s written consent. Grievances and appeals can be filed orally, in writing, or
in person. Provider offices must maintain copies of MCNA’s grievance and appeal forms for use by the members
upon their request. To file a grievance or appeal contact MCNA’s Member Services or send the request via mail
to MCNA's Grievances and Appeals Department. Phone numbers and address are located in Section 2 (MCNA
Contact Information) of this manual.
The member or member’s representative can give MCNA more information about the appeal. Information can be
provided in person or in writing. The member also has the right to review their appeal at any time, and to ask for
copies of the information MCNA utilized during the review of the appeal. Upon request, MCNA will also provide a
written copy of the reasons behind an appeal determination.
At no time will a member or provider be discriminated against because he or she has filed an appeal or a
grievance. We respect our members’ privacy. Anything they say or write is kept confidential.
10.10.1. Grievance Process

A member can file a grievance if they are dissatisfied with the quality of care or services received, dissatisfied with
the behavior of a provider or a member of the provider’s staff, or feel the provider failed to respect their rights. A
member may file a grievance at any time. Upon receipt, MCNA will review the member’s grievance and respond
in writing within 30 calendar days from the date that MCNA received the grievance. A 14-calendar day extension
is possible if one of the following circumstances exists:
• The member asks for an extension
• MCNA determines that there is a need for additional information and the delay is in the member’s best
interests. MCNA will notify the member of the reason for the delay in writing within two (2) calendar days
of the determination
10.10.2. Appeal Process

MCNA will notify the member and requesting provider if we deny or limit authorization of a requested service,
including the type or level of service, or if we reduce, suspend, or terminate a previously authorized service. If the
member, member’s representative, or provider disagrees with our decision, he or she can file an appeal. Appeals
filed by a provider on behalf of a member or a member’s representative require the member’s written consent.
The written consent must be received within 60 calendar days of the date of the denial. An appeal can also be
filed if MCNA denies, in whole or in part, payment for a service; fail to provide services in a timely manner; fail to
act within specified timeframes; or a deny a request to obtain services outside the network for specific reasons.
An appeal may be filed orally or in writing within 60 calendar days of the date of the denial. If there is an oral
request, a written notice must be received from the member within 10 calendar days of when the member
contacts MCNA to request an appeal. Upon receipt of the written request, the Grievances and Appeals
Department will review the action or decision by MCNA related to covered services or services provided.
We will respond to the member in writing within 30 calendar days from the date that we received the appeal. A 14
calendar day extension is possible if one of the following circumstances exists:
• The member asks for an extension
• MCNA determines that there is a need for additional information and the delay is in the member’s best
interests. MCNA will notify the member of the reason for the delay in writing within two (2) calendar days
of the determination
10.10.3. Urgent or Expedited Appeals

If the member’s appeal is about care that is medically necessary and needed soon, a dental provider other than
the dental provider rendering the original denial decision, will review the appeal on an expedited basis. An
expedited review process is available for a member appeal that is for pre-service medical necessity and an
expedited review request may be filed orally or in writing This expedited review process may take place when
MCNA determines or the provider/practitioner indicates that taking the time for a standard resolution could
seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function.
MCNA will decide on an expedited review no later than 48 hours after we receive the member’s appeal request.
We will respond to the request either by phone, fax, or mail.
If MCNA denies a request for expedited resolution of an appeal, the appeal will be transferred to standard
resolution of appeal timeframe of 30 calendar days. MCNA will contact the member by telephone by close of
business and follow up within two (2) calendar days with a written notice.
10.10.4. Continuation of Benefits

If the member requests continuation of benefits, the member’s benefits will not end while MCNA reviews the case
unless the member is removed from Medicaid. If the member is currently receiving authorized services that are
now denied and the member wishes to continue to get these services, he or she must request an appeal in writing
within 10 calendar days of the denial letter or within 10 calendar days after the intended effective date of the
action, whichever is later. The request must clearly state that the member wishes to continue receiving the
services. Services may be continued until the appeal decision is made. If, however, the appeal decision agrees
with MCNA denial, the member may have to pay for the services.
The member has the right to request a Medicaid Fair Hearing within 120 calendar days from the date of MCNA’s
appeal determination. MCNA’s internal appeal process must be exhausted before the member may request a
Medicaid Fair Hearing. To request a Medicaid Fair Hearing, the member must contact the Agency for Health Care
Administration at:
Agency for Health Care Administration
Medicaid Hearing Unit
P.O. Box 60127
Fort Myers, FL 33906
Phone: (877) 254-1055 (toll-free)
Fax: (239) 338-2642
Email: MedicaidHearingUnit@ahca.myflorida.com
Section 11: Utilization Management
11. Utilization Management

Utilization Management (UM) is the process of influencing the continuum of care by evaluating the necessity and
efficiency of dental care services and affecting patient care decisions through assessments of the
appropriateness of care. The UM department helps to assure prompt delivery of medically-appropriate dental care
services to MCNA members and subsequently monitors the quality of care and services delivered. MCNA
implemented the UM Program to ensure that access is being given to all members across the MCNA provider
network, to maintain and establish guidelines for appropriateness of care and to ensure that care is rendered due
to medical/dental necessity.
The Chief Dental Officer is responsible for overseeing the dental management utilization plan and maintaining a
consistent process for authorizations. The guidelines of the plan must be consistent and in compliance with the
state and federal law.
MCNA’s UM department meets the requirements of the Florida Medicaid Dental Services Coverage and
Limitation Handbook, as well as the requirements of the American Dental Association (ADA) and the American
Academy for Pediatric Dentistry (AAPD). All decisions made by the Chief Dental Officer and Dental Clinical
Reviewers shall be fair and impartial, and set forth within the guidelines of MCNA and Florida Medicaid. These
criteria are reviewed annually by the Chief Dental Officer and Utilization (Advisory) Management Committee. The
committee consists of general dentists and specialists who are currently practicing dentistry in the community and
includes a minimum of one specialist from each dental specialty.
All pre-authorizations, post service authorizations are approved by the Chief Dental Officer and/or Clinical
Reviewers. All denials made on the clinical level are made by a licensed dentist. Any authorization, and/or
payment request submitted that is not consistent with the MCNA criteria and guidelines will be denied.
All dental services will be provided in accordance with guidelines established in the current Florida Medicaid
Dental Services Coverage and Limitations Handbook, as well as any limitations and/or exclusions put forth in the
handbook. The policies that MCNA utilizes are based on the following source materials:
• Standards of American Academy of Pediatric Dentistry (AADP)
• Standards of the American Dental Association (ADA)
• Current Medicaid Dental Services Coverage and Limitation Handbook
Updates to UM policies, including guidelines, are communicated to providers via MCNA’s online Provider Portal at
http://portal.mcna.net.
MCNA provides the opportunity for the provider to discuss a decision with the Chief Dental Officer, to ask
questions about a UM issue, or to seek information from a Clinical Reviewer about the UM process and the
authorization of care by calling MCNA (See Section 2: MCNA Contact Information). After business hours or on
holidays, a provider may leave a message, and a representative will return the call the next business day.
MCNA monitors for the over- and underutilization of dental care services within its network. UM decision-making
is based only on appropriateness of care and services and existence of coverage. MCNA does not reward
practitioners or other individuals conducting utilization review for issuing denials of coverage or services.
MCNA will not enter into any contractual arrangement that rewards participating providers or any other individuals
who may conduct utilization review activities for issuing denial of coverage of service or any other financial
incentives for utilization decision making. Quality of care will not be affected by financial and reimbursement-
related processes and decisions.
MCNA complies with the following requirements:
• Compensation for utilization management activities ARE NOT structured to provide inappropriate
incentives for denials, limitations, or discontinuation of authorization of services
• Compensation programs for MCNA Dental Clinical Reviewers, Dental Officers/Directors, or staff that
make clinical determinations DO NOT include any incentives for denial of medically necessary services
• MCNA continuously monitors the potential effects of any incentive plan on access and/or quality of care
11.1. Specialist Referral

Members do not need a referral to access dental specialists. Members may contact MCNA (See Section 2:
MCNA Contact Information) or use our Provider Locator at locator.mcna.net to find a participating specialist.
11.2. Authorizations
The UM department at MCNA has a set of criteria and guidelines to authorize procedures that need to be
approved by the Chief Dental Officer or a Clinical Reviewer prior to treatment being rendered within the setting of
a general dentist or specialist. These criteria ensure adherence to the standards of the Florida Medicaid
guidelines.
For services that require prior authorization, participating providers are required to obtain prior authorization from
MCNA’s UM department before treatment is rendered, unless there are extenuating circumstances (dental
emergencies).
11.2.1. Utilization Review Guidelines for Dental Services that Require Prior Authorization
Services that require pre-authorization should not begin before prior authorization has been received for non-
emergency care. Providers are responsible for verifying member eligibility and benefits before providing services
to MCNA members. If treatment is provided prior to the determination of coverage, the provider does so at his/her
own financial risk. The provider is financially responsible and cannot balance bill the member if coverage is
denied.
Authorization requests are reviewed against MCNA approved criteria such as the American Academy of Pediatric
Dentistry Guidelines (http://www.aapd.org) and the American Dental Association Guidelines
(http://ebd.ada.org/en/evidence/guidelines).
Per the Provider Agreement, the provider must hold MCNA, the member, plan, and the state harmless if coverage
is denied for failure to obtain prior authorization, whether before or after service is rendered.
The provider should complete and submit the Pre-Authorization Form along with any required supporting
documentation, such as x-rays, narratives, photos, etc. to MCNA’s UM department. Electronic submissions
require that the supporting documentation needed, including x-rays, be included electronically. Upon receipt of the
Pre-Authorization Form, the UM staff date stamps the form and verifies the member‘s eligibility and benefits as
well as the dentist’s/specialist’s network affiliation. Additional information is requested and collected from the
provider’s office as needed.
Prior authorization requests may be submitted electronically via MCNA’s Provider Portal (http://portal.mcna.net/),
or may be mailed to the UM department (See Section 2: MCNA Contact Information), Attn: Utilization
Management - Pre-Authorizations.
Note: Prior authorization requests faxed will not be accepted.
Once a determination has been made, the prior authorization will be available to view on the Provider Portal. If
required, the UM department will mail the prior authorization letter to the dentist within five (5) calendar days of
the determination for standard requests and within 24 hours for emergency requests (emergency services do not
require pre-authorization). There will be an authorization number assigned for service; this number must be
submitted with the claim after services are rendered. After receiving an approval via the Provider Portal or regular
mail, the provider should contact the member and schedule the authorized services. Approved pre-authorizations
are effective for 365 days from the date they are posted on the Provider Portal or mailed to the provider.
11.3. Emergency Authorizations

MCNA ensures that members have access to emergency care, without prior authorization, and to services and
treatment as provided through the state agreement and defined in federal and state regulations. MCNA ensures
that members have the right to access emergency dental care services, consistent with the need for such
services. A dental emergency is defined as an oral condition that occurs suddenly and creates an urgent need for
professional consultation and/or treatment. The clinical condition may include hemorrhage, infection, pain, or
trauma.
Prior-authorization for emergency care or hospital emergency room treatment is not required. Authorization prior
to emergency treatment may not be possible. In those instances the provider is required to submit the same
documentation with the claim post-treatment as is needed in the submission of a request for prior authorization.
Claims submitted without this documentation will be denied.
11.4. Additional Visit and Ongoing Care Treatment Plan

If additional visits and/or treatments or ongoing care are deemed necessary by the Primary Dental Provider and
the specialist, a treatment plan is developed jointly and a pre-authorization is submitted through the Provider
Portal or mailed to the MCNA UM department for review. It must include the following information:
• Date
• Patient name and ID number
• Primary Dental Provider name
• Dental specialist name and specialty
• Number of visits or services requesting
• Frequency of visits
• Dental CDT codes
• Other required information, such as x-rays or narrative
Upon receipt of the pre-authorization, the UM staff reviews the information for coverage and benefits issues. The
dental information is reviewed for necessity and appropriateness of care by the Chief Dental Officer or a Clinical
Reviewer.
Based on dental necessity and appropriateness of care, the UM staff will complete the pre-authorization for
additional visits and services as appropriate. Should further visits be required a new pre-authorization must be
submitted and approved by MCNA prior to further treatment.
11.5. Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols, dental policies, or
failure to follow administrative procedures outlined in the Provider Agreement or this Provider Manual.
11.5.1. Medical-Necessity Denials

Utilization Management utilizes dental policies, protocols, and industry standard criteria and guidelines to render
review decisions. Requests not meeting the criteria and guidelines, protocols, or policies are referred to the Chief
Dental Officer or a Clinical Reviewer for clinical review. The Chief Dental Officer or a Clinical Reviewer renders all
denial decisions. At any time during MCNA’s normal hours of operations, the requesting provider may contact the
Chief Dental Officer or a Clinical Reviewer by telephone to discuss a decision, the information used to reach a
decision, request a copy of the criteria utilized in a decision, or request a peer-to-peer consultation regarding a
UM decision. To speak with the Chief Dental Officer or a Clinical Reviewer, please contact the Utilization
Management department (See Section 2: MCNA Contact Information).
Section 12: Treatment
12. Treatment
12.1. Second Opinion

The Primary Dental Provider (PDP) should discuss all aspects of the treatment plan with the member prior to
beginning the treatment to address all of the member’s concerns and questions. If the member indicates they
would like a second opinion, inform them they may do so and that MCNA will cover the cost of a second opinion if
they see a provider within the MCNA network. Please inform the member they will need to contact Member
Services to arrange the consultation with another participating provider. The PDP must provide copies of the
chart, radiographs, and any other information to the provider performing the second opinion upon request.
12.2. Preventive Treatment

Members should be encouraged to return to their PDP for a recall visit as frequently as indicated by their
individual oral status and within plan time parameters. It is important that each dental office have a recall
procedure in place. The following should be accomplished at each recall visit:
• Update medical history
• Review of oral hygiene practices and provision of necessary instruction
• Complete prophylaxis and periodontal maintenance procedures
• Topical application of fluoride, if indicated
• Sealant application, if indicated
12.3. Participating Hospitals

Contracted dental providers may be required to provide dental services at participating hospitals. Pre-
authorization is required for the use of surgical facilities for outpatient treatment.
12.4. Special Needs Patients

Special needs patients are defined as those patients who have a physical, behavioral, developmental, or
emotional condition that prohibits them from adequately responding to a provider’s attempts to perform an
examination.
Members may be classified as special needs when a provider has adequately documented the specific condition
and the reasons why an examination and treatment cannot be performed without general or intravenous sedation.
Members or providers may contact Case Management to initiate the assessment process for members with
conditions that are medically compromising or otherwise physically or mentally disabled. Our Case Management
Coordinators will act as a liaison between the member and provider in all aspects of arranging care, including
coordinating travel arrangements, communication services, facilitating treatment pre-authorization, and other
needs while the member is in active care. Case Management Coordinators also assist in scheduling follow-up
care.
12.5. Decision Making Criteria and Guidelines

MCNA reviews the generally accepted dental standards of the American Academy of Pediatric Dentistry
(http://www.aapd.org), the American Dental Association (http://www.ada.org), and the Florida Medicaid Dental
Services Coverage and Limitations Handbook when creating our internal decision-making criteria. The criteria are
changed and enhanced as needed. MCNA also complies with the Center for Medicare and Medicaid Services
(CMS) national coverage decisions and written decisions of local carriers and intermediaries with jurisdiction for
claims in the geographic area in which services are covered.
The procedure codes used by MCNA are described in the American Dental Association’s Code Manual. Requests
for documentation of these codes are determined by community accepted dental standards for authorization such
as treatment plans, narratives, radiographs, and periodontal charting.
MCNA’s Utilization Management Committee reviews these criteria annually. They are designed as guidelines for
authorization and payment decisions and are not intended to be absolute. MCNA appreciates your input regarding
the criteria are used for decision-making. Please contact the Provider Hotline (See Section 2: MCNA Contact
Information) to comment or make suggestions. A copy or access of the criteria is made available to providers
upon request.
12.6. Guidelines for Preventive Dental Care and Chronic Dental Conditions
The Clinical Practice Guidelines are based on the enrolled membership and dictate the provision of acute and
chronic dental care services to assist providers and members in making appropriate dental care decisions to
improve quality of care. Practice Guidelines are developed based on the following criteria:
• Reasonable, sound, and scientific medical evidence
• Prevalence of dental conditions
• Extent of variation present in current clinical practice patterns
• Magnitude of quality of care issues based on existing patterns of clinical practice
• Ability to impact on practice patterns
• Consideration of the needs of the members
• Strength of evidence to support best clinical practice management strategies
• Ability to achieve consensus on an optional strategy
MCNA has adopted the American Academy of Pediatric Dentistry (AAPD) (http://www.aapd.org) policies on:
• Use of Fluoride and the Policy on Early Childhood Caries (ECC); Classifications, Consequences, and
Preventive Strategies
• Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for
Infants, Children, and Adolescents
• Caries-risk Assessment and Management for Infants, Children, and Adolescents
• Xylitol Use in Caries Prevention
• Pulp Therapy for Primary and Immature Permanent Teeth
• Fluoride Therapy
• Periodontal Therapy
MCNA references the American Dental Association (http://www.ada.org) clinical recommendations for:
• Non-fluoride Caries Preventive Agents
• Fluoride Supplements
• Sealants
• Topical Fluoride
Types of diagnostic and preventive services are:
• Regular dental exams
• Routine cleanings
• Fluoridation or fluoride therapy
• Dental sealants
• X-rays
• Good home care
• Patient education
Definition of Services:
• Diagnostic Services: oral evaluations, x-rays, and treatment planning
• Preventive Services: prophylaxis, x-rays, fluoride, sealants, and Oral Hygiene Instructions (OHI)
• Therapeutic Services: restoring diseased tooth structure and providing necessary treatment for optimal
oral health
• Emergency Services: appropriateness of handling and referring emergencies
To review MCNA’s Clinical Practice Guidelines, please visit our website at https://www.mcnafl.net/dentists/.
Section 13: Quality Improvement
13. Quality Improvement
13.1. Quality Improvement Program

The goal of the MCNA Quality Improvement (QI) Program is to ensure that each member has affordable and
convenient access to quality dental care delivered in a timely manner by a network of credentialed providers. The
Board of Directors of MCNA is responsible for establishing the priorities of the QI Program based on the
recommendations of the MCNA Dental Management Committee.
The Quality Improvement Committee oversees the QI Program to ensure that the performance of all quality
improvement functions is timely, consistent, and effective. This committee reports to the Board of Directors and
carries out the following responsibilities:
• Oversees the implementation of the QI Program throughout MCNA’s operational departments
• Establishes a method to measure and quantify improvements in dental care delivery to MCNA members
resulting from QI initiatives
• Reviews and makes recommendations, which are identified through the QI process, for approval of all
new and revised policies, procedures, and MCNA benefit designs
• Ensures that adequate resources are allocated toward the achievement of MCNA’s QI Program goals
• Oversees the management of all aspects of MCNA’s operations to make sure they are consistent with the
goals and objectives of the QI Program
• Monitors the progress of all MCNA-initiated corrective action plans
• Monitors the integration, coordination, and supervision of Risk Management Program activities through
the formal reporting of those activities
• Demonstrates compliance with regulatory requirements and delegation standards
• Assesses and confirms that quality care and services are being appropriately delivered to MCNA
members
• Reports quarterly to the Board of Directors the status of MCNA QI Program
A copy of the QI Program is available to all participating providers upon request. Please contact the Provider
Hotline (See Section 2: Contact Information).
13.2. Your Role in Quality

Every MCNA network dentist is a participant in the QI Program through his or her contractual agreement with
MCNA. You may be asked to serve on any of the committees that are part of the QI Program or contribute to the
development of clinical practice guidelines, dental record audits, member education programs, Performance
Improvement Projects (PIPs), and other quality initiatives. Your participation is invaluable to these initiatives that
are central to quality improvement. Participation on a committee is voluntary.
You can help us identify any issues that may directly or indirectly impact both member care and outcomes by
reporting them on an Incident Report Form, which can be downloaded on our online Provider Portal. The forms
can be submitted to MCNA via fax, email, or alternate means.
The MCNA Chief Dental Officer may contact your office regarding your Incident Report. Please keep a copy of a
member’s Incident Report in the member’s dental record.
Providers are expected to engage in outreach activities geared toward members and encourage them to seek
dental care.
13.3. Quality Enhancement Programs (Focus Studies)

MCNA monitors and evaluates the quality and appropriateness of care and service delivery (or the failure to
provide care or deliver services) to members and providers through performance improvement projects (PIPs),
dental record audits, performance measures, surveys, and related activities. As a provider for Medicaid, MCNA
will perform no fewer than three (3) state-approved PIPs per year. The PIPs will focus on both clinical and
nonclinical areas.
13.4. Quality Review of Key Performance Clinical and Service Indicators

One of MCNA’s QI Program objectives is to perform a quality review of key clinical and service indicators through
analysis of member and provider data to assess and improve member and provider satisfaction rates. These
clinical and service indicators include reviews of the following:
• Member and provider complaints for care or service
• Sentinel events defined as any adverse event involving member care that warrants further investigation
for quality of care concerns
• National Committee for Quality Assurance’s (NCQA’s) Healthcare Effectiveness Data and Information Set
(HEDIS®) annual dental visit measure
• Application of clinical guidelines for preventive services
• Application of appropriate dental record documentation and continuity and coordination of care standards
• Health outcome intervention activities and focused studies
• Member claims and encounters
• Member pre-authorization requests
The dental records of all MCNA members must be made available upon request to support the review of each of
the indicators described in this and previous sections.
13.5. Corrective Action

When the Quality Improvement (QI) Program identifies specific cases of substandard quality of care during its
review process, a letter requesting corrective action will be mailed to the treating provider. There are many forms
of corrective action that may be recommended. Some examples of corrective action are listed below:
• A Corrective Action Letter indicating the deficiency or deficiencies and requiring changes to be
implemented within a maximum of 60 days (the seriousness of the deficiency or deficiencies noted will
dictate the number of days which the provider has to implement the required changes)
• Special pre-authorization/claims review
• Post-treatment reviews of patients by a Clinical Reviewer
• Provider attendance at training sessions or participation in continuing education programs
• Restriction of acceptance of new members until the provider becomes compliant with all standards of
care for a given amount of time
• Recoupment of sums paid where billing discrepancies are found during reviews
• Restriction of a provider’s authorized scope of services
• Referral to the State Board of Dental Examiners and/or the Department of Justice Attorney General’s
Office
• Termination of Provider Agreement
Where corrective action is recommended, MCNA’s priority is to work with the provider to improve performance
and compliance with all MCNA policies and procedures defined in the Provider Agreement and this manual.
MCNA is willing to provide support to a provider who shows sincere intent to correct deficiencies.
13.6. Member Satisfaction Surveys

The Member Satisfaction Survey is a tool that assists MCNA in rating member experience both with network
providers and with MCNA. The survey addresses key patient issues such as level of satisfaction with MCNA,
access to care, utilization, care received, and interaction with dental staff. The survey may be conducted on a
random basis, with specific offices, or administered in a variety of combinations. MCNA also complies with any
state requirements regarding annual or routine member satisfaction surveys for its population. This information is
used in the implementation of strategies to improve care and service to our members. The results and
improvement strategies will be posted on MCNA’s website at www.mcna.net.
As needed, individual providers will be contacted for individual improvement strategies.
13.7. Provider Satisfaction Surveys

MCNA will assess its contracted Primary Dental Providers’ satisfaction annually. This activity will include, but not
be limited to, analyses of provider satisfaction of the following factors:
• MCNA’s response time to provider inquiries and complaints
• MCNA communication
• Claims payment process
• Authorization process
• MCNA availability and effectiveness
MCNA will use the results of all Provider Satisfaction Survey and any state-approved contracted independent
surveys to develop and implement plan-wide activities designed to improve provider satisfaction.
MCNA will make aggregate survey results available to providers and members upon request.
13.8. Patient Records and Chart Reviews

As specified in MCNA’s Provider Agreement, MCNA is authorized to conduct reviews of plan member treatment
records. These records are chosen randomly for periodic review. The chart review includes assessment of the
following patient elements:
• Recording of medical history, dental history, and existing dental conditions
• Radiograph evaluation and diagnostic material used
• Treatment Plan and timeliness of treatment plan
• Actual care delivered in relation to proposed treatment plan
• Recall protocol and utilization analysis of actual care delivered
• A signed Patient Consent Form
Such review offers MCNA insight into the provider’s practice patterns and includes suggested areas of
improvement based on identified deficiencies. The on-site review is a component of our Quality Improvement
Program. The data is collected and entered into MCNA’s DentalTrac™ database. The data from chart reviews
allows for the development of generalized network and practice patterns along with utilization data. This
contributes to providing the dental office with valuable feedback and information. This information will be used as
part of the re-credentialing process.
13.9. Participating Dentist Criteria

The Participating Dentist Criteria lists a variety of requirements that the participating provider must meet. These
requirements include standards regarding your office’s physical attributes, practice coverage, patient access,
office procedures, office records, insurance and professional qualifications, and work history. These criteria are
used in our credentialing and re-credentialing process and are attached to our current Provider Agreement.
13.10. Applicability
The Participating Dentist Criteria shall apply to each applicant for participation and to providers participating with
MCNA, and shall be enforced by MCNA. The provider must satisfactorily document evidence meeting the criteria
listed for at least six (6) months prior to application unless the applicant has entered clinical practice or completed
a residency or a fellowship program within the past six (6) months or currently participates with MCNA.
Each participating provider must continue to meet the credentialing criteria while participating with MCNA.
To be a participating provider with MCNA, the dentist must be credentialed, must execute a Provider Agreement,
and must agree to provide services to MCNA members.
All dental providers are re-credentialed every three (3) years.
13.11. On-Site Office Survey

The office site survey has two (2) components, prospective and ongoing, for participating offices. Each review
highlights essential areas of the office's management and dental care practices. During the site survey (which
may or may not be scheduled), the following areas will be evaluated:
1. General Information – the name of the practice, address, name of principal owner and associates,
license numbers, staffing information, office hours, list of languages spoken in the office, availability of
appointments, method of providing 24-hour coverage (e.g., answering machine or answering services),
and the name of the covering dentist when the office is closed
2. Practice History – the office provides information regarding malpractice suits, settlements, and
disciplinary actions, if applicable
3. Office Profile – indicates services the office routinely performs
4. Facility Information – includes location, accessibility (including handicap accessibility), description of
interior office (such as the reception area), smoke-free, operatories and lab, type of infection control,
equipment, and radiographic equipment
5. Risk Management – includes review of personal protective equipment (such as gloves, masks, handling
of waste disposal, sterilization and disinfection methods), training programs for staff, radiographic
procedures and safety, occupational hazard control (regarding amalgam, nitrous oxide, and hazardous
chemicals), medical emergency preparedness training and equipment, fire and safety protocols
6. Recall System – includes review of procedures for assuring patients are scheduled for recall
examinations and follow-up treatment
7. Credentialing Verification – verification that all MCNA participating dental providers in a group practice
are credentialed by MCNA
8. Record Keeping – review will ensure MCNA’s participating record keeping practices conform to MCNA’s
organizational standards
MCNA will make the onsite review standards and process description available to providers upon request.
13.12. Credentialing and Re-Credentialing

Credentialing is the review of qualifications and other relevant information pertaining to a dental care professional,
including a Registered Dental Hygienist (RDH), who seeks acceptance into MCNA’s provider network. The
Credentialing Program follows the recommended CMS categories, which include:
• Initial Credentialing – written application, verification of information from primary and secondary
sources, confirmation of eligibility for payment under Medicare and or Medicaid, if applicable, and site
visits as appropriate.
• Monitoring – includes monitoring of lists of practitioners who have been sanctioned and/or had
grievances filed against them and of practitioners who opt-out of accepting federal reimbursement from
Medicare and or Medicaid. Monitoring is done on a regular basis between credentialing and re-
credentialing cycles.
• Re-credentialing – re-evaluation of provider’s credentials at least once every three (3) years through a
process that updates the information obtained during initial credentialing. Re-credentialing considers
performance indicators such as those collected through the Quality Improvement (QI) program, the
Utilization Management system, the Grievance and Appeal system, enrollee satisfaction surveys, and
other activities of the organization. Following the initial credentialing process with MCNA, all of our
network providers who enter into the re-credentialing cycle are considered approved unless otherwise
notified. If you have any questions regarding re-credentialing with MCNA, please contact the Provider
Hotline (See Section 2: Contact Information).
Following the initial credentialing process with MCNA, all of our network providers who complete all re-
credentialing requirements are considered approved unless otherwise notified. If you have any questions
regarding re-credentialing with MCNA, please call our Provider Hotline.
Preventive dental services provided to Medicaid beneficiaries by a RDH employed by or in contractual agreement
with a health access facility may be reimbursed when those services are provided under the general supervision
of a dentist as defined in Florida Statute 466.003 (10).
The Medicaid-enrolled supervising dentist, at the facility where the RDH is employed or in a contractual
agreement, will be listed as the treating provider for these services.
The Credentialing Program establishes the selection criteria for qualification as a participating provider. The
criteria are clearly outlined in the credentialing application and are reviewed and approved by the Credentialing
Committee. Additionally, current copies of the following documents must be attached for initial credentialing as
well as for re-credentialing. These documents are required as components of the selection criteria and will be
verified with primary and secondary sources:
• Florida Dental License
• National Provider Identifier (NPI) Number
• Medicare/Medicaid (CMS) Provider Number
• Medicaid Fee for Service Only: Level 2 background screening by Florida Department of Law Enforcement
• Controlled Substance Registration Certificate from the Drug Enforcement State (DEA)
• Professional Liability Insurance Face Sheet
• Work History (curriculum vitae)
• Board Certificate or Evidence of adequate training
• Completed W-9 Form
• Signed Provider Agreement
• Signed Provider Application
It is the provider’s responsibility to submit any renewal certification documentation or changes in information to
MCNA within 10 business days of any change.
13.13. Credentialing Committee Appeals

In the event an applicant is credentialed with restrictions, denied, or terminated, the Credentialing Committee
offers an opportunity to appeal. An appeal must be requested in writing and must be reviewed by the Committee
within 30 days of the date the committee gave notice of its decision.
When MCNA identifies aberrations related to the quality and appropriateness of care delivered by a participating
provider, the Credentialing Committee evaluates whether the severity of the issue(s) involved require a corrective
action up to and involving suspension or termination from the participating provider network and makes the initial
decision about what action, if warranted, should be taken. Any provider affected by MCNA’s decision to suspend
or terminate that provider from the network has the right to an appeal process.
A copy of MCNA’s credentialing policies can be obtained by contacting the Provider Relations department (See
Section 2: MCNA Contact Information).
13.14. Practitioner Sanctioning Policy

In the event MCNA identifies healthcare services rendered to a MCNA member by a participating dental provider
that are outside the recognized treatment patterns of the organized dental community and quality management
and/or credentialing standards, the practitioner may be subject to sanctions. The National Practitioner Data Bank
(NPDB) may be notified of all negative outcomes if formal sanctioning proceedings are implemented and if the
outcome is to last 30 days or more.
In addition to the above, MCNA’s Compliance department excludes and/or penalizes a provider under any of the
following conditions:
• MCNA has received recommendations to take such actions as a result of an investigation conducted by
the Florida Office of the Inspector General or other appropriate state and/or federal agency
• The provider fails to cooperate with an investigation of alleged fraud and abuse
• The provider has been listed on the Medicare/Medicaid Sanctions Report
Possible sanctions for deviation from accepted quality management and/or credentialing standards and program
integrity violations include:
• Limiting a Primary Dental Provider’s panel
• Termination of participating provider status

• Withholds from future claims payments of amounts that are improperly paid or reasonable estimates of
such amounts
• Suspension of claims activity
13.15. Peer Review Committee

Peer review of professional competency or conduct may result in a proposed adverse action for “medical
disciplinary cause or reason” affecting a provider’s continued participation with MCNA. A “medical disciplinary
cause or reason” refers to an aspect of a provider’s competence or professional conduct that is reasonably likely
to be detrimental to the delivery of patient care. The Chief Dental Officer may immediately initiate corrective action
against a provider for identified medical disciplinary cause, or any other reason where the Chief Dental Officer
reasonably believes that the failure to take such action may result in imminent danger to the health of any
individual.
MCNA’s Peer Review Committee meets as necessary to objectively and methodically assess, evaluate, and
resolve issues related to the quality and appropriateness of care, safety, and service. It determines appropriate
actions to be taken relating to a contracted participating provider’s professional competency or conduct and
quality of care issues. The Peer Review Committee also monitors the results of the improvement strategy that is
implemented and ensures appropriate re-evaluation. The Peer Review Committee serves as the initial committee
that reviews the quality of care occurrence and renders the initial determination. The peer review appeal panel(s)
serve(s) as the tool to allow providers a dispute process where MCNA has made the decision to reduce, suspend,
or terminate their participation in the MCNA provider network.
The Peer Review Committee and peer review appeal panel(s) consist(s) of at least three (3) qualified dentists. Of
those three (3) individuals, at least one (1) must be a dentist who is not otherwise involved in network
management and/or not a clinical peer of the participating provider in question. In addition one (1) dentist must
practice in the same specialty as the provider who is being evaluated. None of the qualified dentists can be
involved in the initial determination and be a panel participant of the previous peer review appeals process.
The provider is notified of the Peer Review Committee’s decision as it is related to quality of care and competency
issues or professional conduct via a certified letter that is sent within 10 business days of the meeting. The letter
will advise the provider of the following:
• The actions and decisions from the committee and of the provider or applicant right to dispute the
decision at the first-level appeal panel
• The process for the provider or applicant to submit their corrective action or request further action from
the Peer Review Committee
• The provider or applicant right to submit a letter disputing the Peer Review Committee’s decision within
30 calendar days of the decision and provide any additional supporting documentation to assist in the
dispute
• The provider or applicant right to request a first-level peer review appeal panel for a reevaluation of the
initial decision
13.16. Peer Review for Provider Disputes

The provider dispute process applies only to contracted network providers. Disputes related to professional
competence or conduct; and quality of care and/or patient safety issues are addressed under the dispute process.
In the event that aberrations are found in the quality or appropriateness of care delivered by a credentialed
provider and sanctions, up to and including termination of participation in MCNA’s network, are brought to bear
against that individual, the provider has the right to enter into a two (2) level appeal process. The provider will
remain an active network provider throughout the appeal process unless MCNA determines there is imminent
harm.
First-Level Provider Appeal: The first-level peer review appeal panel consists of least three (3) qualified
dentists. Of those three (3) individuals, at least one (1) must be a dentist who is not otherwise involved in network
management and/or who is a clinical peer of the participating provider in question, and one (1) dentist must
practice in the same specialty as the provider who is being evaluated. None of the qualified dentists can be
involved in the initial determination and previous peer review appeals process. The peer review appeal panel
evaluates the initial determination made by the Peer Review Committee. The panel evaluates the facts of a case
brought before it by a provider appealing MCNA’s initial decision and determines if the care and service meets the
standard of care. If the dispute brought before the peer review appeals panel is found in favor of the appealing
provider, no further actions are necessary. If MCNA’s initial decision is upheld, the provider may request a
second-level appeal as appropriate.
Second-Level Provider Appeal: A provider has the right to appeal the decision made by the first-level appeal
panel by submitting a formal request for a second-level appeal hearing with all supporting documents. The
second-level appeal function is carried out through MCNA’s peer review appeal hearing panel. The second-level
peer review hearing panel consists of least three (3) qualified dentists who were not involved with the initial and
first-level decision. Of those three (3) individuals, at least one (1) must be a dentist who is not otherwise involved
in network management and/or who is a clinical peer of the participating provider in question, and one (1) dentist
must practice in the same specialty as the provider who is being evaluated. The hearing process is available in
the case or quality of care concerns when MCNA’s proposes to suspend or terminate a participating provider from
the network. At the hearing, the practitioner has the right to:
• Representation by an attorney or other person of the practitioner’s choice
• Have a record made of the proceedings, copies of which may be obtained by the practitioner upon
payment of any reasonable charges associated with the preparation thereof
• Call, examine, and cross-examine witnesses
• Present evidence determined to be relevant by the panel, regardless of its admissibility in a court of law
• Submit a written statement at the close of the hearing
A provider who has submitted a written second-level appeal request will be notified of the anticipated hearing date
by MCNA within 10 business days of the receipt of the request. The notification letter, sent via certified mail, will
include a full listing of the provider’s rights during the hearing, the second-appeal hearing panel participants, and
an explanation that the provider’s failure to be available at the hearing will not delay the decision by the panel.
Section 14: Office Policies and Procedures
14. Office Policies and Procedures
14.1. Office Standards

Each Dentist’s office must:
• Have a sign containing the names of all dentists practicing at the office. The office sign must be visible
when the office is open.
• Have a mechanism for notifying members if a dental hygienist or other non-dentist dental professional
may provide care.
• Be accessible to all patients, including but not limited to its entrance, parking, and bathroom facilities.
• Have offices that are clean, presentable, and have a professional appearance.
• Have clean and properly equipped patient toilet and hand-washing facilities.
• Have a waiting room that will accommodate at least four (4) patients.
• Have treatment rooms that are clean, properly equipped, and contain functional, adequately supplied
hand-washing facilities.
• Have at least one (1) staff person (in addition to the Dentist) on duty during normal office hours.
• Provide a copy of current licenses and certificates for all dentists, dental hygienists, and other non-dentist
dental professionals practicing in the office, including state professional licenses and certificates, Federal
Drug Enforcement and State Controlled Drug Substance licenses and certification (where applicable).
• Keep a file and make available to MCNA any state required practices and protocols or supervising
agreements for dental hygienists and other non-dentist dental professionals practicing in the office.
• Have appropriate, safe x-ray equipment. Radiation protection devices including, without limitation, lead
aprons shall be available and used according to professionally recognized guidelines (e.g. Food and Drug
Administration).
• Maintain a smoke-free facility.
• Ensure proper fire and safety procedures are in place.
• Use appropriate sterilization procedures for instruments; use gloves and disposable needles; maintain the
standards and techniques of safety and sterility in the dental office required by applicable federal, state
and local laws and regulations including, but not limited to, those mandated by OSHA, and as advocated
by the American Dental Association (ADA) and state and local societies.
• Comply with all applicable federal, state, and local laws and regulations regarding the handling of sharps
and environmental waste, including the disposal of waste and solutions.
• Make appointments in an appointment book or an electronic equivalent acceptable to MCNA.
Appointments should be made in a manner that will prevent undue patient waiting time and in compliance
with the access criteria listed in this manual.
• Have documented emergency procedures, including procedures addressing treatment, evacuation, and
transportation plans to provide for the safety of members.
• Prominently display the Agency for Health Care Administration’s statewide Consumer Call Center’s phone
number and hours of operation and a copy of the summary of Florida’s Patient’s Bill of Rights and
Responsibilities. Upon request, provide patients with a copy of their rights and responsibilities as listed in
the manual.
• Have a functional recall system in place for notifying members of the need to schedule dental
appointments. The recall system must include the following requirements for all enrolled members:
1. The system must include either written or verbal notification

2. The system must have procedures for scheduling and notifying members of routine checkups,
follow-up appointments, and cleaning appointments
3. The system must have procedures for the follow up and rescheduling of missed appointments
MCNA encourages its providers to make efforts to decrease the number of “no shows.” It is suggested that the
provider contact the member prior to the appointment either by phone or in writing to remind them of the time and
place of the appointment. Follow-up phone calls or written information should be provided encouraging the
member to reschedule the appointment in the event the appointment is missed. Members cannot be charged for
missed appointments.
14.2. Sterilization and Infection Control

Patient and staff members must be protected from infectious and environmental contaminants.
14.2.1. OSHA Requirements

• All personnel should wash with bacterial soap before all oral procedures
• Sterile gloves should be worn
• All instruments should be thoroughly scrubbed and debrided before sterilization
• All instruments and equipment that cannot be sterilized, including operating light chair switches, hand
pieces, cabinet working surfaces and water/air syringes and their tips, should be disinfected, using
approved techniques, after each use
• ADA approved sterilization solutions should be utilized
• All equipment should be monitored using process indicators with each load and spore testing on a weekly
basis
• Handling of all environmental waste, including the disposal of waste and solutions, must be in compliance
with all applicable federal, state, and local laws and regulations
14.3. Medical Emergencies

All office staff shall be prepared to deal with any medical emergency through the implementation of the following
guidelines:
• The dentist and at least one (1) other staff must have current CPR training
• The dental office must have a formal medical emergency plan and staff members must understand their
individual responsibilities
• All emergency numbers must be posted prominently
• Patients with medical risk shall be identified in advance
• All dental offices must have a portable source of oxygen with a positive demand valve, blood pressure
cuff, and stethoscope
14.4. Dental Records Standards

The provider shall ensure maintenance of dental records for each enrollee in accordance with this section. Dental
records shall include the quality, quantity, appropriateness, and timeliness of services performed as required by
the Provider Agreement.
The provider shall follow the dental record standards set forth below for each enrollee's dental records, as
appropriate:
1. Include the enrollee’s identifying information, including name, enrollee identification number, date of birth,
gender, and legal guardianship (if any).
2. Each record shall be legible and maintained in detail.
3. Include a summary of significant surgical procedures, past and current diagnoses or problems, allergies,
untoward reactions to drugs, and current medications.
4. All entries shall be dated and signed by the appropriate party.

5. All entries shall indicate the chief complaint or purpose of the visit, the objective, diagnoses, diagnostic
findings, or impression of the provider.
6. All entries shall indicate studies ordered and referral reports.
7. All entries shall indicate therapies administered and prescribed.
8. All entries shall include the name and profession of the provider rendering services (e.g., DDS), including
the signature or initials of the provider.
9. All entries shall include the disposition, recommendations, instructions to the enrollee, evidence of
whether there was follow-up, and outcome of services.
10. All records shall contain a record of any emergency services and care and any appropriate medically
indicated follow-up.
11. Document referral services in enrollees' dental records.
12. Include all services provided.
13. All records shall reflect the primary language spoken by the enrollee and any translation needs of the
enrollee.
14. All records shall identify enrollees needing communication assistance in the delivery of dental care
services.
15. All records shall contain documentation that the enrollee was provided with written information concerning
the enrollee’s rights regarding advance directives (written instructions for living will or power of attorney)
and whether or not the enrollee has executed an advance directive. Neither the MCNA, nor any of its
providers shall, as a condition of treatment, require the enrollee to execute or waive an advance directive.
16. Contain copies of any advance directives executed by the enrollee.
17. Captures any dental services provided to its members by non-PDHP providers.
18. Any and all medical and dental records, including but not limited to graphic matter, photos, x-ray images,
and related matter that were necessary to produce a diagnostic or therapeutic report shall be retained,
preserved, safeguarded, and properly stored (whether electronic or paper) for a minimum period of ten
(10) years from the date an enrollee is last treated by the provider.
14.4.1. Confidentiality of Dental Records

• The provider shall have a policy to ensure the confidentiality of dental records in accordance with 42
CFR, Part 431, Subpart F
• The provider will ensure compliance with the privacy and security provisions of the Health Insurance
Portability and Accountability Act (HIPAA)
14.5. Access to Dental Records

As an MCNA-contracted provider, you are required to ensure that an accurate and complete member dental
record is established and maintained and allow MCNA’s authorized personnel, its designated representatives,
review organizations, and government agencies on-site access to such records during regular business hours. If
requested, you must provide MCNA with the following records according to timelines, definitions, formats, and
instructions specified by MCNA:
• All information required under the Provider Agreement, including but not limited to records, reports, and
other information related to your performance of obligations under the agreement
In addition, you are required to provide the following entities or their designees with prompt, reasonable, and
adequate access to the Provider Agreement and any records, books, documents, and papers that are related to
the agreement and/or your performance of responsibilities under the agreement:
• MCNA authorized personnel

• Florida Agency for Health Care Administration
• Florida Medicaid Program Integrity
• Florida Office of Inspector General
• State or federal law enforcement agency
• Any other state or federal entity identified by MCNA
You must also provide access to the location or facility where such records, books, documents, and papers are
maintained and you must provide reasonable comfort, furnishings, equipment, and other conveniences necessary
to fulfill any of the following described purposes:
• Audits and investigations
• Contract administration
• The making of copies, excerpts, or transcripts
• Any other purpose MCNA deems necessary for contract enforcement or to perform our regulatory
functions
Section 15: Dental Services
15. Dental Services

Dental services are those services and procedures rendered by a Florida-licensed dentist in an office, clinic,
hospital, ambulatory surgical center, or elsewhere when dictated by the need for diagnostic, preventive,
therapeutic, or palliative care, or for the treatment of a particular injury as specified in the current Florida Medicaid
Dental Services Coverage and Limitations Handbook.
15.1. Florida Medicaid Dental Services (Children, Ages 0 to 20)

Florida Medicaid children’s dental services include diagnostic services, preventive treatment, restorative
treatment, endodontic treatment, periodontal treatment, surgical procedures and/or extractions, orthodontic
treatment, and complete and partial dentures, as well as complete and partial denture relines and repairs. Also
included are adjunctive general services, injectable medications, and oral and maxillofacial surgery services. All
dental services are to be provided in accordance with guidelines established in the current Florida Medicaid
Dental Services Coverage and Limitations Handbook, as well as any limitations and/or exclusions put forth in the
Handbook.
15.2. Florida Medicaid Dental Services (Adults, Ages 21 and Over)

The adult dental program provides for the reimbursement of complete and removable partial dentures. Extractions
and other surgical procedures essential to the preparation of the mouth for dentures are reimbursable if the
patient is to receive dentures. Procedures relating to dentures such as repairs, relines, and adjustments are
reimbursable.
Medicaid will reimburse for medically necessary emergency dental procedures to alleviate pain and/or infection
for eligible adult Medicaid recipients 21 years of age or older. Emergency dental care shall be limited to
emergency problem-focused evaluations, radiographs necessary for diagnosis, extractions, and incision and
drainage of abscess.
15.3. Emergency Services

MCNA notifies all members of the provisions governing emergency services and care. MCNA will not deny claims
for emergency services and care received at a hospital. In addition, MCNA will not deny payment for treatment
obtained when a representative of MCNA instructs the member to seek emergency services and care in
accordance with s. 743.064, F.S.
MCNA will not take any of the following actions:
• Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency
services and care
• Specify or imply that emergency services and care are covered by MCNA only if secured within a certain
period of time
• Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered
• Deny payment based on a failure by the enrollee or the hospital to notify the MCNA before, or within a
certain period of time after, emergency services and care were given
When a member presents at a hospital seeking emergency services and care, the determination that an
emergency dental condition exists shall be made, for the purposes of treatment, by a physician or dentist of the
hospital or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a
hospital dentist. See Florida Statutes 409.9128, 409.901, and 641.513.
The dentist, or the appropriate personnel, shall indicate on the member's chart the results of all screenings,
examinations, and evaluations. MCNA will cover all screenings, evaluations, and examinations that are
reasonably calculated to assist the provider in arriving at the determination as to whether the member’s condition
is an emergency dental condition.
If the provider determines that an emergency dental condition does not exist, MCNA is not required to cover
services rendered subsequent to the provider's determination unless authorized by MCNA.
If the provider determines that an emergency dental condition exists and the member notifies the hospital or the
hospital emergency personnel, or the hospital otherwise has knowledge that the patient is a member of MCNA,
the hospital must make a reasonable attempt to notify either one of the following:
• The member's PDP, if known,
• MCNA, if MCNA has previously requested in writing that it be notified directly of the existence of the
emergency dental condition
15.4. Facility Setting Dental Treatment

Any treatment provided in a facility setting, as opposed to a non-facility office setting, that is related to one of the
following circumstances must be clearly documented in the member’s dental record:
• The member’s health will be so jeopardized that the procedures cannot be performed safely in the office
• The member is uncontrollable due to emotional instability or developmental disability and sedation has
proven to be an ineffective intervention
MCNA will be responsible for coordinating this care. Additionally, MCNA will be responsible for the payment of
any dental claims associated with the member’s time at the facility.
15.5. Telemedicine
The practice of health care delivery by a practitioner who is located at a site other than the site where a recipient
is located for the purposes of evaluation, diagnosis, or treatment. Florida Medicaid reimburses for telemedicine
services using interactive telecommunications equipment that includes, at a minimum, audio and video equipment
permitting two-way, real time, interactive communication between a recipient and a practitioner. The following
must be met when providing services through telemedicine:
• The telecommunication equipment and telemedicine operations meet the technical safeguards required
by 45 CFR 164.312, where applicable
• Must comply with Health Insurance Portability and Accountability Act and other State and Federal laws
pertaining to patient privacy
• Will not be reimbursed for telephone conversations, chart review(s), electronic mail messages, or
facsimile transmissions.
• Will not be reimbursed for equipment required to provide telemedicine services.
• Must be approved by MCNA to provide telemedicine
MCNA is committed to working with providers to leverage available innovative technology when it can safely and
effectively enhance a member’s experience. As dentistry is such a tactile practice, we encourage providers to see
and treat patients in-person as much as possible. This is possible in most cases as our Florida network is so
extensive.
In instances where it is impractical to see a member in a physical practitioner’s office, MCNA encourages
providers to work collaboratively to deliver care via teledentistry. This may include instances when a PDP requires
a specialist consult, which the PDP is capable of facilitating using the appropriate telecommunications equipment.
Our Provider Agreement with network dentists who choose to provide teledentistry requires the provider to have
key fraud and abuse protocols that address:
(a) Authentication and authorization of users;
(b) Authentication of the origin of the information;
(c) The prevention of unauthorized access to the system or information;
(d) System security, including the integrity of information that is collected, program integrity and system
integrity; and
(e) Maintenance of documentation about system and information usage.
MCNA’s Provider Relations team works closely with providers interested in conducting teledentistry visits to
ensure they have the support necessary to implement this technology. According to the ADA, teledentistry
includes patient care and education delivery using the following modalities:
• Live Video
o A two-way interaction between a patient, caregiver, or provider, and a provider using audio/visual
telecommunications technology.
• Store-and-Forward
o A transmission of recorded health information such as x-rays, photographs, video, or digital
impressions of patients through a secure, electronic means to a provider who uses the
information to diagnose a patient's condition or render services outside of a live interaction.
• Remote Patient Monitoring (RPM)
o Involves the collection of personal health and medical data from an individual in one location by
electronic communication technologies, which is transmitted to a provider in a different location
for use in delivering dental care.
• Mobile Health
o Involves health care service delivery and dental education through the use of mobile
communication devices such as cell phones, tablets, and computers.
15.6. Tele-Care Peer-to-Peer Link

MCNA has developed our Tele-Care Peer-to-Peer link that will be available to our network providers via MCNA's
Provider Portal. This link enables all participating providers to share radiographs, charting, and narratives with
their peers through our secure, HIPAA-compliant online portal. The Tele-Care Peer-to-Peer link has been
specifically designed by MCNA to facilitate teledentistry and increase access to dental specialist consultations. To
take advantage of this resource, log in to your Provider Portal account at http://portal.mcna.net.
15.7. Oral and Maxillofacial Surgery Services

Oral and maxillofacial surgery services provide medically necessary dental treatment of any disease or injury to
the maxillary or mandibular areas of the head or any structure contiguous to those areas, and the reduction of any
fracture in those areas. These are services furnished by a dentist that would be considered physician services if a
physician had furnished them. The more complex of these procedures are usually provided in an inpatient or
outpatient hospital or ambulatory surgical center setting, although not exclusively.
15.8. Orthodontic Services

Orthodontic services are limited to a child whose malocclusion creates a disability and/or impairment to his or her
physical development. Orthodontic services that are primarily for cosmetic purposes are not a covered benefit.
15.9. Out-of-Network Use of Non-Emergency Services

MCNA will provide timely approval or denial of authorization of out-of-network use through the assignment of a
prior authorization number, which refers to and documents the approval.
15.10. Caries Risk Assessment

In accordance with standards of practice and policy guidelines set forth by the American Academy of Pediatric
Dentistry, a Dental Home provider may perform a caries risk assessment as part of the comprehensive oral
examination to track and stratify a member’s risk level. Providers may bill one of the following caries risk
assessment codes per member, per year: D0601, D0602, or D0603 with a comprehensive oral evaluation
(D0150), oral evaluation for a patient under three (3) years of age (D0145), or periodic oral evaluation (D0120).
These risk assessment codes will be included as part of an informational component of the D0150, D0145, or
D0120 billing code. Dental Home providers will receive a $5.00 payment for each appropriately billed risk code
when submitted in conjunction with a qualifying exam, limited to one per year per member.
Providers must clearly document the individual patient’s oral condition(s) that justifies the risk assessment
classification submitted with the claim. Documentation must be maintained in the member’s dental record. The
results may be provided using a recognized caries risk assessment tool or through a narrative addressing caries
risk factors.
Section 16: Dental Guidelines
16. Dental Guidelines

MCNA’s Utilization Management Criteria uses components of dental standards from the American Academy of
Pediatric Dentistry (www.aapd.org), the American Dental Association (www.ada.org), and the Florida Medicaid
Dental Limitations and Coverage Handbook. MCNA’s criteria are changed and enhanced as needed.
The procedure codes used by MCNA are described in the American Dental Association’s Code Manual. Requests
for documentation of these codes are determined by community accepted dental standards for authorization such
as treatment plans, narratives, radiographs, and periodontal charting.
These criteria are approved and annually reviewed by MCNA’s Utilization Management Committee. They are
designed as guidelines for authorization and payment decisions and are not intended to be absolute. Please refer
to the covered services sections of this Provider Manual for a list of all codes covered under the program by
member age range and plan. You will find additional limitations and requirements for coverage.
16.1. Quick Reference Guide for ADA Codes Requiring Prior Authorization
Below is a Quick Reference Guide listing the American Dental Association (ADA) Codes that require authorization
or may be reviewed after the dental treatment has been performed. For complete benefits and limitations, please
see the Covered Services sections of this manual.
PERIODONTICS
D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING – FOUR OR MORE CONTIGUOUS TEETH OR TOOTH
BOUNDED SPACES PER QUADRANT
D4241 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING – ONE TO THREE CONTIGUOUS TEETH OR TOOTH
BOUNDED SPACES PER QUADRANT
PROSTHODONTICS
D5110 COMPLETE DENTURE - MAXILLARY
D5120 COMPLETE DENTURE - MANDIBULAR
D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE
D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE
D5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES
D5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES
D5820 INTERIM PARTIAL DENTURE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH), MAXILLARY
D5821 INTERIM PARTIAL DENTURE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH), MANDIBULAR
D5899 UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE, BY REPORT
OTHER IMPLANT SERVICES
D6096 REMOVE BROKEN IMPLANT RETAINING SCREW
OTHER FIXED PARTIAL DENTAL SERVICES
D6985 PEDIATRIC PARTIAL DENTURE, FIXED
ORAL SURGERY
D7880 OCCLUSAL ORTHOTIC DEVICE, BY REPORT
D7999 UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT
ORTHODONTICS
D8070 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
D8080 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION
D8090 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION
D8210 REMOVABLE APPLIANCE THERAPY
D8220 FIXED APPLIANCE THERAPY
D8670 PERIODIC ORTHODONTIC TREATMENT VISIT
D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF RETAINER(S))
D8703 REPLACEMENT OF LOST OR BROKEN RETAINER - MAXILLARY
D8704 REPLACEMENT OF LOST OR BROKEN RETAINER - MANDIBULAR
D8999 UNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORT
SEDATION
D9999 UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT
When submitting claims for the CDT codes listed above, please review additional code limitations found under the
Covered Services section.
16.2. Guidelines for X-Rays
16.2.1. Criteria
• Must be of diagnostic quality
• All x-rays must be labeled as Right or Left
• Must be labeled with the member’s name
• Must be labeled with the date x-rays were taken
16.3. Guidelines for Crowns
16.3.1. Criteria
• Criteria for crowns will be met only for permanent teeth needing multi-surface restorations where other
restorative procedures have a poor prognosis
• Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and should
involve four (4) or more surfaces and two (2) or more cusps.
• Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and should
involve three (3) or more surfaces and at least one (1) cusp.
• Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma, and must
involve four (4) or more surfaces and at least 50% of the incisal edge.
Note: To meet criteria, a crown must be opposed to a tooth or denture in the opposite arch or be an abutment for
a partial denture.
Crowns will not meet criteria if:
• A lesser invasive restoration is possible
• Tooth has subosseous and/or furcation caries
• Tooth has advanced periodontal disease
• Crowns are being planned to alter vertical dimension
16.4. Guidelines for Crowns following Root Canal Therapy
16.4.1. Criteria
• Tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved,
unless there is a curvature or calcification of the canal that limits the provider’s ability to fill the canal to
the apex
• The filling must be properly condensed/obturated; filling material does not extend excessively beyond the
apex
• The permanent tooth must be at least 50% supported in bone and cannot have mobility grades +2 or +3
16.4.2. Documentation Required for Authorization

• Submit appropriate radiographs with authorization request: periapical or panoramic
• Submit radiographs showing clearly the adjacent and opposing teeth with the claim for review of payment
• Claims request should include a dated radiograph of RCT, if RCT was completed by submitting provider.
16.4.3. Procedure Codes

• D2928, Prefabricated porcelain/ceramic crown – permanent tooth
• D2930, Prefabricated stainless steel crown primary tooth

• D2931, Prefabricated stainless steel crown permanent tooth
• D2932, Prefabricated resin crown
• D2933, Prefabricated stainless steel crown with resin window
• D2934, Prefabricated esthetic coated stainless steel crown primary
16.5. Guidelines for Core Build Up
16.5.1. Criteria
• The foundation of the tooth is insufficient to place a crown
• Performed on a previously satisfactorily endodontically treated tooth to provide a foundation to place a
crown
• Not covered on primary teeth

• Submit appropriate radiographs with authorization request: periapical.
• Requires post-operative endodontic x-ray in order to approve prefabricated post and core

• D2950, Core buildup, including any pins when required
• D2951, Pin retention per tooth, in addition to restoration
• D2954, Prefabricated post and core in addition to a crown
16.6. Guidelines for Endodontics
16.6.1. Criteria
• The tooth is infected and/or abscessed
• Trauma or fracture that damages the pulp
• The pulp of the primary tooth is infected and the exfoliation of the deciduous tooth is not anticipated within
six (6) months (for pulpotomy or pulpectomy only)
• Tooth must demonstrate at least 50% bone support and cannot have mobility grades +2 or +3
• Root canal therapy not in anticipation of placement of an overdenture
• Tooth must be able to be restored to form and function
16.6.2. Criteria for Retreatment of Root Canal

• Overfilled canal
• Underfilled canal
• Broken instrument in canal that is not retrievable
• Root canal filling material lying free in periapical tissues and acting as an irritant
• Perforation of the root in the apical one-third of the canal, which will cause a denial for a retreatment
• Fractured root tip is not reachable, which will cause a denial for a retreatment
16.6.3. Criteria for Apexification

• The apex of the root is not closed and needs to be treated so closure can be achieved (usually after
trauma)
16.6.4. Criteria for Apicoectomy and Retrograde Filling

• The apex of the tooth needs to be removed because the surrounding area is infected and/or has an
abscess; it requires a filling to be placed in the apical part of the tooth to seal that part of the root canal
• Perforation of the root in the apical one-third of the canal

• Submit appropriate radiographs with authorization request: periapical
• Emergency treatment will require a dated pre- and post-operative radiograph for claims review
• In situations where pathology is not apparent, a written narrative justifying treatment is required
16.6.6. Other Considerations

• Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging
the canals, temporary fillings, filling and obliteration of root canal(s), and progress radiographs, including
a final root canal fill radiograph.
• In cases where the endodontic therapy does not meet MCNA’s treatment standards, MCNA can require
the endodontic retreatment to be performed at no additional cost. Any reimbursement already made for
an inadequate service may be recouped after MCNA reviews the circumstances.

• D3310, Endodontic therapy, anterior tooth (excluding final restoration)
• D3320, Endodontic therapy, premolar tooth (excluding final restoration)
• D3330, Endodontic therapy, molar tooth (excluding final restoration)
• D3220, Therapeutic pulpotomy (excluding final restoration)
• D3240, Pupal therapy (resorbable filling) – posterior, primary tooth
• D3352, Apexification / recalcification interim visit
• D3410, Apicoectomy – anterior
• D3430, Retrograde filling – per root
16.7. Guidelines for Periodontal Treatment
16.7.1. Criteria
• Periodontal charting indicates abnormal pocket depths in multiple sites; probing depths must be 4mm or
greater
• Radiographic evidence of root surface calculus
• Radiographic evidence of noticeable loss of bone support. Attachment loss with the appearance of
reduction of the alveolar crest beyond 1-1 1/2mm proximity to the cement-enamel junction (CEJ)
exclusive of gingival recession
16.7.2. Criteria for Gingivectomy

• Presence of diseased malformed or excess gingival tissue due to systemic disease or pharmacological
induced gingival hyperplasia
16.7.3. Criteria for Full Mouth Debridement

• Presence of significant gingival inflammation and/or supragingival calculus, that interferes with the ability
of the dentist to perform a comprehensive oral evaluation.

• Submit appropriate radiographs with authorization request: bitewings or periapical preferred
• Complete periodontal charting

• Narrative
• Photograph is required for CDT codes D4210, D4211, D4240, D4241, D4346, and D4355

• D4210, Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per
quadrant
• D4211, Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per
quadrant
• D4240, Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded
spaces per quadrant
• D4241, Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded
spaces per quadrant
• D4260, Osseous surgery (including elevation of a full thickness flap and closure) – four or more
contiguous teeth or tooth bounded spaces per quadrant
• D4261, Osseous surgery (including elevation of a full thickness flap and closure) – one to three
contiguous teeth or tooth bounded spaces per quadrant
• D4341, Periodontal scaling and root planning – four or more teeth per quadrant
• D4342, Periodontal scaling and root planing – one to three teeth per quadrant
• D4346, Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after
oral evaluation
• D4355, Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a
subsequent visit
16.8. Guidelines for Removable Prosthodontics (Complete and Partial Dentures)
16.8.1. Criteria
• Favorable prognosis is present
• Abutment teeth are more than 50% supported in bone
• Adjustments, repairs, and relines are allowed when there are extenuating circumstances, and/or in the
case of medical necessity
• All prosthetic appliances shall be inserted into the mouth before a claim is submitted for payment
• The overall condition of the mouth is an important consideration in whether or not a partial denture is
authorized. For partial dentures, abutment teeth must be caries-free or have been completely restored
and have sound periodontal support. For those members requiring extensive restorations, periodontal
services, extractions, etc., clinical/operative notes may be requested with the claim for coverage
consideration.
• Partial dentures that replace only posterior teeth must occlude against multiple posterior teeth in the
opposing arch and must serve to increase masticatory function and stability of the entire mouth.
• Only permanent teeth are eligible for replacement by a partial denture.
• A denture is determined to be an initial placement if the member has never worn a prosthesis (this refers
to entire lifetime, not only the time frame during which the member has been receiving treatment from a
specific provider).
• The delivery date of the denture and/or partial denture is the billing date of service (DOS).
Authorizations for removable prosthesis will not meet criteria if extensive repairs are performed on marginally
functional partial dentures, or when a new partial denture would be better for the health of the recipient. However,
adding teeth and/or clasp to a partial denture is a covered benefit if the addition makes the dentures functional.

• Submit appropriate radiographs with authorization request: bitewings, periapical or panorex
• Submit narrative/rationale and teeth numbers that will be replaced for D5211, D5212, D5213, and D5214

Complete Dentures
• D5110, Complete denture maxillary (upper)
• D5120, Complete denture mandibular (lower)
Partial Dentures
• D5211, Maxillary partial denture - resin base
• D5212, Mandibular partial denture - resin base
• D5213, Maxillary partial denture - cast metal framework with resin denture base
• D5214, Mandibular partial denture - cast metal framework with resin denture base
Adjustments to Dentures
• D5410, Adjust complete denture – maxillary
• D5411, Adjust complete denture – mandibular
• D5421, Adjust partial denture – maxillary
• D5422, Adjust partial denture – mandibular
Repairs to Complete Dentures
• D5511, Repair broken complete denture base, mandibular
• D5512, Repair broken complete denture base, maxillary
• D5520, Replace missing or broken teeth - complete denture (each tooth)
Repairs to Partial Dentures
• D5611, Repair resin partial denture base, mandibular
• D5612, Repair resin partial denture base, maxillary
• D5621, Repair cast partial framework, mandibular
• D5622, Repair cast partial framework, maxillary
• D5630, Repair or replace broken clasp
• D5640, Replace broken teeth - per tooth
• D5650, Add tooth to existing partial denture
• D5660, Add clasp to existing partial denture
Denture Reline Procedures
• D5730, Reline complete maxillary denture (direct)
• D5731, Reline complete mandibular denture (direct)
• D5740, Reline maxillary partial denture (direct)
• D5741, Reline mandibular partial denture (direct)
• D5750, Reline complete maxillary denture (indirect)
• D5751, Reline complete mandibular (indirect)
• D5760, Reline maxillary partial denture (indirect)
• D5761, Reline mandibular partial denture (indirect)
Interim Prosthesis
• D5820, Interim partial denture – maxillary
• D5821, Interim partial denture – mandibular
16.9. Guidelines for Oral Surgery

Uncomplicated extractions, removal of soft tissue impactions, or minor surgical procedures are considered basic
services and are the responsibility of the Primary Dental Provider (PDP). The member may be referred to a
contracted MCNA oral surgeon when it is beyond the scope of the PDP.
16.9.1. Criteria
• A tooth broken below the bone level
• Supernumerary tooth
• Dentigerous cyst
• Untreatable periodontal disease
• Pathology not treatable by other means
• Recurrent pericoronitis
• Non-restorable carious lesion
• Pain and/or swelling due to impeded eruption
• Orthodontic extractions (requires approval)
• Exfoliation of a deciduous tooth not anticipated within six (6) months
• No extractions of third molars if roots are not substantially formed
• Alveoloplasty (D7310) in conjunction with four (4) or more extractions in the same quadrant
• No benefit for the extraction of asymptomatic teeth
• Extractions are not payable for deciduous teeth when normal loss is imminent

• Submit appropriate radiographs with authorization request: bitewings, periapical or panoramic
• Narrative demonstrating medical necessity

• D7210, D7220, Surgical removal of erupted tooth
• D7230, D7240, D7241, Surgical removal of impacted teeth
• D7250, Surgical removal of residual roots
• D7280, Exposure of an unerupted tooth
• D7310, Alveoloplasty in conjunction with extraction
• D7510, Incision and drainage of abscess
16.9.4. Code Descriptions

• D7140 - extraction, erupted tooth or exposed root (Elevation and/or forceps removal)
Includes routine removal of tooth structure, minor smoothing of socket of socket bone, and closure, as
necessary
• D7210 - extraction erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated
Includes related cutting of gingival and bone, removal of tooth structures, minor smoothing of socket
bone, and closure
• D7220 - removal of impacted - soft tissue
Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation
• D7230 - removal of impacted tooth - partially bony
Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal
• D7240 - removal of impacted tooth - completely bony
Most or all crown covered by bone; requires mucoperiosteal flap elevation and bone removal
• D7241 - removal of impacted tooth-complete bony, with unusual surgical complications
Most or all of crown covered by bone; usually difficult or complicated due to factors such as nerve
dissection required, separate closure of maxillary sinus required or aberrant tooth position
• D7250 - removal of residual tooth roots (cutting procedure)
Includes cutting of soft tissue and bone, removal of tooth structure, and closure
16.10. Guidelines for Orthodontics
16.10.1. Criteria for Orthodontics

• Prior authorization is required for all orthodontic services
• Orthodontic services are limited to those recipients under the age of 21 whose handicapping
malocclusion creates a disability and impairment to their physical development
• A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health
and interferes with the well-being of the patient by causing impaired mastication, dysfunction of the
temporomandibular articulation, susceptibility to periodontal disease, susceptibility to dental caries, and
impaired speech due to malpositions of the teeth
Criteria for approval is limited to one (1) of the following conditions:
• Correction of severe handicapping malocclusion as measured in the Medicaid Orthodontic Initial
Assessment Form (IAF)
• Syndromes involving the head and maxillary or mandible jaws such as cleft lip or cleft palate
• Cross-bite therapy, with the exception of one (1) posterior tooth that is causing no occlusal interferences
• Head injury involving traumatic deviation
• Orthognathic surgery, to include extractions, required or provided in conjunction with the application of
braces
For a complete description of the orthodontic guidelines, see AHCA’s Medicaid Orthodontic Initial Assessment
Form in Section 19: Forms of this manual.

Pre-authorization for orthodontic services requires the following documentation:
• Completed and signed Pre-Authorization Request Form
• Clinical photographs (prints or slides) showing:
o Frontal view, relaxed, teeth in occlusion
o Profile, right or left
o Intraoral, right or left sides, teeth in occlusion
o Intraoral, frontal, teeth in occlusion
o Occlusal view (if photos are submitted without complete records),
• Panoramic or full mouth intraoral radiographs
• Lateral cephalometric radiograph
• Diagnostic quality study models (or OrthoCad equivalent) are not required but will help to provide
information of qualification of the patient. Please note: Instead of submitting physical study models with a
prior authorization request, providers are encouraged to submit diagnostic quality digital images of the
study models.
16.11. Guidelines for Anesthesia
16.11.1. Requirements
• Dentists providing sedation or anesthesia services must have the appropriate certification from the Florida
State Board of Dentistry for the level of sedation or anesthesia provided
• MCNA must have on file a copy of the certification prior to rendering sedation services
16.11.2. Criteria
Acceptable conditions include, but are not limited to, one or more of the following:
• Documented local anesthesia toxicity
• Severe cognitive impairment or developmental disability
• Severe physical disability

• Uncontrolled management problem
• Extensive or complicated surgical procedures
• Failure of local anesthesia
• Documented medical complications
• Acute infections

• D9222, Deep sedation/general anesthesia - first 15 minutes
• D9223, Deep sedation/general anesthesia - each subsequent 15 minute increment
• D9230, Inhalation of nitrous oxide/analgesia, anxiolysis
• D9239, Intravenous moderate (conscious) sedation/analgesia - first 15 minutes
• D9243, Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
• D9248, Non intravenous conscious sedation
16.12. Miscellaneous Services
16.12.1. Criteria for Medical Immobilization Including Papoose Boards

The provider must obtain a written informed consent from the legal guardian and document it in the member’s
dental record prior to medical immobilization.
The member’s dental record must include:
• Informed consent
• Type of immobilization used
• Indication for immobilization
• The duration of application
Goals of behavior management:
• Establish communication
• Alleviate fear and anxiety
• Deliver quality dental care
• Build a trusting relationship between dentist and child
• Promote the child’s positive attitude toward oral/dental health
Section 17: Covered Services: Children (0-20)
17. Covered Services: Children (0-20)

All services billed must have supporting clinical documentation in the patient’s medical record. Services
performed on a per-quadrant or per-tooth basis must include the quadrant or tooth ID on the claim.
Claims are denied if the procedure code is not compatible with TID or SID. Use the alpha characters to describe
tooth surfaces or any combination of surfaces. For SID designation on anterior teeth, use facial (F) and incisal (I).
For SID purposes, use buccal (B) and occlusal (O) designations for posterior teeth.
Each identified permanent tooth and each identified primary tooth has its own identifiable supernumerary number.
This developed system can be found in the Current Dental Terminology (CDT) published by the ADA.
Permanent Teeth Upper Arch
Tooth Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Super Number 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
Permanent Teeth Lower Arch

Tooth Number 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Super Number 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67
Primary Teeth Upper Arch

Tooth Number A B C D E F G H I J
Super Number AS BS CS DS ES FS GS HS IS JS
Primary Teeth Lower Arch

Tooth Number T S R Q P O N M L K
Super Number TS SS RS QS PS OS NS MS LS KS
17.1. Diagnostic Services
17.1.1. Clinical Oral Evaluations

• Procedure codes D0120, D0150, and D0145 are not reimbursable on the same date of service.
• One (1) of D0120, D0145, or D0150 per 6 months per provider, facility, or group.
Code Description Additional Code Limitations
D0120 Periodic oral evaluation - established patient

D0140 Limited oral evaluation - problem focused Not to be used as follow-up care.
D0145 Oral evaluation for a patient under three (3) years of age Age 0-35 months.
and counseling with primary care
D0150 Comprehensive oral evaluation - new or established Limited to once every three (3) years per provider, facility, or group.
patient
17.1.2. Pre-diagnostic Services

D0190 Screening of a patient (DOH or FQHC only) Limited to one (1) every 181 days.
D0191 Assessment of a patient (DOH or FQHC only) Limited to one (1) every 181 days.
17.1.3. Caries Risk Assessment

• Must be submitted in conjunction with a comprehensive oral evaluation (D0150), oral evaluation for a
patient under three (3) years of age (D0145), or periodic oral evaluation (D0120).
D0601 Caries risk assessment, low risk Limited to once per year per member. Claims for this service must
include a valid exam code (D0120, D0145, or D0150) on the same
claim.
D0602 Caries risk assessment, moderate risk Limited to once per year per member. Claims for this service must
claim.
D0603 Caries risk assessment, high risk Limited to once per year per member. Claims for this service must
claim.
17.1.4. Radiographs/Diagnostic Imaging (Including Interpretation)

• The fee for a comprehensive series of radiographic images (D0210) will be applied when an office
submits a combination of periapical x-rays, bitewing x-rays, or panoramic x-rays exceeding the
reimbursable value of the comprehensive series of radiographic images..
D0210 Intraoral – comprehensive series of radiographic images Limited to one (1) every 3 years by the same provider, facility, or
group.
D0220 Intraoral – periapical first radiographic image Requires tooth ID.
D0230 Intraoral – periapical each additional radiographic image Requires tooth ID.
D0240 Intraoral – occlusal radiographic image Requires arch ID.
D0250 Extra-oral – 2D projection radiographic image created
using a stationary radiation source, and detector
D0251 Extra-oral posterior dental radiographic image
D0270 Bitewing – single radiographic image Limited to one (1) per 6 months.
D0272 Bitewings – two (2) radiographic images Limited to one (1) per 6 months.
D0274 Bitewings – four (4) radiographic images Limited to one (1) per 6 months.
D0330 Panoramic radiographic image Limited to one (1) every 3 years by the same provider, facility, or
group.
D0340 2D cephalometric radiographic image – acquisition,
measurement and analysis
D0350 2D oral/facial photographic image obtained intra-orally or

extra-orally
17.1.5. Tests and Examinations

D0470 Diagnostic casts For orthodontic purposes.
17.2. Preventive Services
17.2.1. Dental Prophylaxis

• Nonsurgical Periodontal Services will not be reimbursed with a prophylaxis on the same date of service.
• One (1) D1110, D1120, or D4346 every 6 months.
D1110 Prophylaxis – adult Age 12-20.

D1120 Prophylaxis – child Age Birth-11.
17.2.2. Topical Fluoride Treatment (Office Procedure)

• Application of fluoride to a tooth prior to restoration is not covered.
D1206 Topical application of fluoride varnish Limited to one (1) D1206 or D1208 every 3 months, per patient ages
0-5 years. Limited to one (1) D1206 or D1208 every 6 months, per
patient ages 6 years and above.
D1208 Topical application of fluoride – excluding varnish Limited to one (1) D1206 or D1208 every 3 months, per patient ages
0-5 years. Limited to one (1) D1206 or D1208 every 6 months, per
patient ages 6 years and above.
17.2.3. Other Preventive Services

D1330 Oral hygiene instructions Limited to one (1) every 6 months. Not reimbursable on the same
date of service as D0145.
D1351 Sealant – per tooth Limited to once per three (3) years, per tooth. Requires tooth ID.
First, second, and third permanent molars only – 1, 2, 3, 14, 15, 16,
17, 18, 19, 30, 31, 32.
D1354 Application of caries arresting medicament – per tooth Limited to once per tooth, every 6 months. Requires tooth ID.
D1355 Caries preventive medicament application - per tooth Limited to once per tooth, every 6 months. Requires tooth ID.
17.2.4. Space Maintenance (Passive Appliances)

• Limited to fixed appliances, including unilateral and bilateral, and must be passive in nature.
• A space maintainer will not be reimbursed by MCNA if the space will be maintained for less than six (6)
months.
• The billing provider is responsible for replacement and re-cementation or re-bonding within the first 12
months after placement of the space maintainer. Limited to fixed appliances, including unilateral and
bilateral, that are passive in nature. A space maintainer will not be reimbursed if the space will be
maintained for less than six (6) months. Fixed-space maintainers are limited to the necessary
maintenance of a posterior space for a permanent successor to a prematurely lost deciduous tooth
(teeth).
• Procedure codes D1510 and D1575 are reimbursable for quadrants 10, 20, 30, and 40.
D1510 Space maintainer - fixed unilateral – per quadrant Must include quadrant (10, 20, 30 or 40).
D1516 Space maintainer – fixed – bilateral, maxillary
D1517 Space maintainer – fixed – bilateral, mandibular
D1551 Re-cement or re-bond bilateral space maintainer –
maxillary
D1552 Re-cement or re-bond bilateral space maintainer –
mandibular
D1553 Re-cement or re-bond unilateral space maintainer – per
quadrant
D1556 Removal of fixed unilateral space maintainer – per Requires quadrant or tooth ID.
quadrant
D1557 Removal of fixed bilateral space maintainer – maxillary Limited to one (1) per year per patient.
D1558 Removal of fixed bilateral space maintainer - mandibular Limited to one (1) per year per patient.
D1575 Distal shoe space maintainer - fixed, unilateral – per Must include quadrant (10, 20, 30 or 40) or tooth ID.
quadrant
17.3. Restorative Services
17.3.1. Amalgam Restorations (Including Polishing)

• One (1) restoration every three (3) years per tooth number or letter per surface.
• The fee for restorations includes local anesthesia, tooth preparation, routine lining and base, etching, an
adhesive such as a resin bonding agent, and curing the restoration.
• MCNA will not reimburse for restorations on primary teeth when loss is expected within six (6) months.
• All restorative services are subject to medical necessity review. Payment is made for restorative services
based on the number of surfaces restored, not on the number of restorations per surface, or per tooth,
per day. A restoration is considered a two (2) or more surface restoration only when two (2) or more
actual tooth surfaces are involved, whether they are connected or not.
• The surfaces that may be billed as restored can be any one or combination of five (5) of the seven (7)
recognized tooth surfaces: mesial, distal, occlusal (or incisal), lingual, or facial (or buccal).
• The original billing provider, facility or group is responsible for the replacement of the original restoration
within the first 36 months after initial placement. Duplicate surfaces are not payable on the same tooth in
a 36-month period by same provider, facility, or group. All restored surfaces on a single tooth shall be
considered connected. The fee for any additional restorative service(s) on the same tooth will be cut back
to the maximum restorative fee for the combined number of non-duplicated surfaces when performed
within a 36-month period by same provider, facility, or group.
D2140 Amalgam - one (1) surface - primary or permanent

D2150 Amalgam - two (2) surfaces - primary or permanent
D2160 Amalgam - three (3) surfaces - primary or permanent
D2161 Amalgam - four (4) or more surfaces - primary or
permanent
17.3.2. Resin-Based Composite Restorations - Direct

• One (1) restoration every three (3) years per tooth number or letter, per surface.
D2330 Resin-based composite – one (1) surface, anterior

D2331 Resin-based composite – two (2) surfaces, anterior
D2332 Resin-based composite – three (3) surfaces, anterior
D2335 Resin-based composite – four (4) or more surfaces or
involving incisal angle (anterior)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite – one (1) surface, posterior
D2392 Resin-based composite – two (2) surfaces, posterior
D2393 Resin-based composite – three (3) surfaces, posterior
D2394 Resin-based composite – four (4) or more surfaces,
posterior
17.3.3. Crowns - Single Restorations Only

• MCNA will not reimburse for crowns provided solely for cosmetic reasons.
• Only covered if the tooth cannot be restored with an amalgam or resin restoration.
• The delivery/seating date of the crown is the billing date of service.
D2710 Crown - resin-based composite (indirect) Pre-payment review required. Submit pre-operative x-rays with claim.
D2721 Crown - resin with predominantly base metal Pre-payment review required. Submit pre-operative x-rays with claim.
D2740 Crown - porcelain/ceramic Pre-payment review required. Submit pre-operative x-rays with claim.
D2751 Crown - porcelain fused to predominantly base metal Pre-payment review required. Submit pre-operative x-rays with claim.
17.3.4. Other Restorative Services

• Reimbursement for post & core is contingent upon satisfactorily completed root canal therapy. For these
services to qualify for reimbursement, the root canal therapy must be completed to an acceptable
standard of care and evidence may be requested.
• Crowns only covered if the tooth cannot be restored with an amalgam or resin restoration.
• Will not reimburse for restorations on primary teeth when tooth loss is expected within six (6) months.
• The delivery date of the crown is the billing date of service (DOS).
D2920 Re-cement or re-bond crown Once per lifetime per tooth. Not covered within 6 months of initial
placement.
D2928 Prefabricated porcelain/ceramic crown - permanent tooth Limited to one (1) D2928 or D2931 per 60-months per tooth.
Requires tooth ID 1-32.
D2930 Prefabricated stainless steel crown - primary tooth Requires tooth ID.
D2931 Prefabricated stainless steel crown - permanent tooth Limited to one (1) D2928 or D2931 per 60-months per tooth.
Requires tooth ID 1-32.
D2932 Prefabricated resin crown Requires tooth ID.
D2933 Prefabricated stainless steel crown with resin window Requires tooth ID.
D2940 Protective restoration Not covered in conjunction with other restorative procedures.
Requires tooth ID.
D2950 Core buildup, including any pins when required Requires tooth ID.
D2951 Pin retention – per tooth, in addition to restoration Requires tooth ID.
D2954 Prefabricated post and core in addition to crown Requires tooth ID.
17.4. Endodontic Services
17.4.1. Pulp Capping

D3110 Pulp cap - direct (excluding final restoration) Requires tooth ID.
D3120 Pulp cap - indirect (excluding final restoration) Requires tooth ID.
17.4.2. Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) Requires tooth ID.

removal of pulp coronal
D3221 Pulpal debridement, primary and permanent teeth Requires tooth ID.
D3222 Partial pulpotomy for apexogenesis - permanent tooth with Requires tooth ID.
incomplete root development
17.4.3. Endodontic Therapy on Primary Teeth

D3230 Pulpal therapy (resorbable filling)-anterior, primary tooth One D3230 per lifetime per patient per tooth. Requires tooth ID.
(excluding final restoration)
D3240 Pulpal therapy (resorbable filling)-posterior, primary tooth One D3240 per lifetime per patient per tooth. Requires tooth ID.
(excluding final restoration)
17.4.4. Endodontic Therapy (Including Treatment Plan, Clinical Procedures, and Follow-up Care)
• Root canal therapy (RCT) is reimbursable:
o For teeth that have restorable crowns, and
o If the prognosis of the tooth is not questionable for periodontal reasons.
• A pulpotomy will not be reimbursed separately. It is considered part of the root canal therapy.
• All endodontic treatment is inclusive of all intra-operative radiographs. The member is not responsible for
these individual charges.
• In order for these services to qualify for reimbursement, the root canal therapy must be completed to an
acceptable standard of care.
D3310 Endodontic therapy, anterior tooth (excluding final Requires pre-payment review. Must submit pre- and post-operative x-
restoration) rays with claim. One D3310 per lifetime per patient per tooth.
D3320 Endodontic therapy, premolar tooth (excluding final One D3320 per lifetime per patient per tooth.
restoration)
D3330 Endodontic therapy, molar tooth (excluding final One D3330 per lifetime per patient per tooth.
restoration)
D3331 Treatment of root canal obstruction; non-surgical access
D3333 Internal root repair of perforation defects One D3333 per lifetime per patient per tooth.
17.4.5. Apexification/Recalcification Procedures

D3351 Apexification/recalcification - initial visit (apical One D3351 per lifetime per patient per tooth.
closure/calcific repair)
D3352 Apexification/recalcification - interim medication One D3352 per lifetime per patient per tooth.
replacement
D3353 Apexification/recalcification - final visit (includes completed One D3353 per lifetime per patient per tooth.
root canal therapy)
17.4.6. Apicoectomy/Periradicular Services

D3410 Apicoectomy - anterior One D3410 per lifetime per patient per tooth.
D3430 Retrograde filling - per root One D3430 per lifetime per patient per tooth.
17.5. Periodontal Services
17.5.1. Surgical Periodontal Services

D4210 Gingivectomy or gingivoplasty - four (4) or more contiguous One D4210 or D4211 per 36 months per patient per quadrant.
teeth or tooth bounded spaces per quadrant Requires pre-payment review. Must submit pre-operative x-rays or
photos and perio charting with claim.
D4211 Gingivectomy or gingivoplasty - one (1) to three (3) One D4210 or D4211 per 36 months per patient per quadrant.
contiguous teeth or tooth bounded spaces per quadrant Requires pre-payment review. Must submit pre-operative x-rays or
photos and perio charting with claim.
D4240 Gingival flap procedure, including root planing - four (4) or Requires pre-authorization, quadrant, narrative/rationale x-rays,
more contiguous teeth or tooth bounded spaces per photos and periodontal charting.
quadrant
D4241 Gingival flap procedure, including root planing - one (1) to Requires pre-authorization, quadrant, narrative/rationale x-rays,
three (3) contiguous teeth or tooth bounded spaces per photos and periodontal charting.
quadrant
D4260 Osseous surgery (including flap entry and closure) - four One D4260 or D4261 per 36 months per patient per quadrant.
(4) or more contiguous teeth or tooth bounded spaces per Requires pre-payment review. Must submit pre-operative x-rays or
quadrant photos and perio charting with claim.
D4261 Osseous surgery (including flap entry and closure) - one One D4260 or D4261 per 36 months per patient per quadrant.
(1) to three (3) contiguous teeth or tooth bounded spaces Requires pre-payment review. Must submit pre-operative x-rays or
per quadrant photos and perio charting with claim.
17.5.2. Nonsurgical Periodontal Services

• Nonsurgical Periodontal Services will not be reimbursed with a prophylaxis on the same date of service.
D4341 Periodontal scaling and root planing – four (4) or more One D4341 or D4342 per 36 months per patient per quadrant. Not
teeth per quadrant allowed on the same date as D1110, D1120, D4346, D4355, D4910.
Requires pre-payment review. Must submit quadrant, x-rays, and
periodontal charting with claim.
D4342 Periodontal scaling and root planing - one (1) to three (3) One D4341 or D4342 per 36 months per patient per quadrant. Not
teeth, per quadrant allowed on the same date as D1110, D1120, D4346, D4355, D4910.
Requires pre-payment review. Must submit quadrant, x-rays, and
periodontal charting with claim.
D4346 Scaling in presence of generalized moderate or severe Limited to one (1) D1110, D1120, or D4346 per 6 months per patient.
gingival inflammation - full mouth, after oral evaluation.
D4355 Full mouth debridement to enable a comprehensive Limited to one (1) D4355 per 12 months per patient. This procedure
periodontal evaluation and diagnosis on a subsequent visit will not be reimbursed if payment has previously been made for
D1110, D1120, or any 4000-series code within a 12-month period.
17.6. Prosthodontic (Removable) Services
17.6.1. Complete Dentures (Including Routine Post Delivery Care)

• Limited to once per lifetime. Exceptions may be granted if the dentures are no longer functional because
of the enrollee’s physical condition or the condition of the denture.
• The delivery/seating date of the complete denture is the billing date of service.
D5110 Complete denture - maxillary Requires pre-authorization narrative/rationale and x-ray/ color
photos. One (1) D5110, D5211, or D5213 per lifetime, per patient
D5120 Complete denture - mandibular Requires pre-authorization narrative/rationale and x-rays/ color
photos. One (1) D5120, D5212, or D5214 per lifetime, per patient
17.6.2. Partial Dentures (Including Routine Post Delivery Care)

• The delivery date of the partial denture is the billing date of service (DOS). The overall condition of the
mouth is an important consideration in whether a partial denture is authorized. For partial dentures,
abutment teeth must be caries-free or have been completely restored and have sound periodontal
support.
• Documentation submitted with the prior authorization must show that all restorations, extractions, and
periodontal treatment has been completed.
D5211 Maxillary partial denture - resin base (including Requires pre-authorization and x-rays, narrative/rationale, and teeth
retentive/clasping materials, rests, and teeth) that will be replaced. One (1) D5110, D5211, or D5213 per lifetime,
per patient.
D5212 Mandibular partial denture - resin base (including Requires pre-authorization and x-rays, narrative/rationale, and teeth
per patient.
D5213 Maxillary partial denture - cast metal framework with resin Requires pre-authorization and x-rays, narrative/rationale, and teeth
denture bases that will be replaced. One (1) D5110, D5211, or D5213 per lifetime,
per patient.
D5214 Mandibular partial denture - cast metal framework with Requires pre-authorization and x-rays, narrative/rationale, and teeth
resin denture bases that will be replaced. One (1) D5120, D5212, or D5214 per lifetime,
per patient.
17.6.3. Adjustments to Dentures

Considered inclusive within 6 months of seating of partial or complete dentures.
D5410 Adjust complete denture - maxillary

D5411 Adjust complete denture - mandibular
D5421 Adjust partial denture - maxillary
D5422 Adjust partial denture - mandibular
17.6.4. Repairs to Complete Dentures

Considered inclusive within 6 months of seating of complete dentures.
D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary
D5520 Replace missing or broken teeth - complete denture (each
tooth)
17.6.5. Repairs to Partial Dentures

Considered inclusive within six (6) months of seating of partial dentures.
D5611 Repair resin partial denture base, mandibular Limited to three (3) per 12 months.
D5612 Repair resin partial denture base, maxillary Limited to three (3) per 12 months.
D5621 Repair cast partial framework, mandibular Limited to three (3) per 12 months.
D5622 Repair cast partial framework, maxillary Limited to three (3) per 12 months.
D5630 Repair or replace broken retentive/clasping materials – per

tooth
D5640 Replace broken teeth - per tooth Limited to one (1) per 12 months, per provider.
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
17.6.6. Denture Reline Procedures

• Considered inclusive within six (6) months of seating of partial or complete dentures.
D5730 Reline complete maxillary denture (direct) Limited to one (1) D5730 per year per patient.
D5731 Reline complete mandibular denture (direct) Limited to one (1) D5731 per year per patient.
D5740 Reline maxillary partial denture (direct) Limited to one (1) D5740 per year per patient.
D5741 Reline mandibular partial denture (direct) Limited to one (1) D5741 per year per patient.
D5750 Reline complete maxillary denture (indirect) Limited to one (1) D5750 per year per patient.
D5751 Reline complete mandibular denture (indirect) Limited to one (1) D5751 per year per patient.
D5760 Reline maxillary partial denture (indirect) Limited to one (1) D5760 per year per patient.
D5761 Reline mandibular partial denture (indirect) Limited to one (1) D5761 per year per patient.
17.6.7. Interim Prosthesis

D5820 Interim partial denture (maxillary) Requires pre-authorization and x-rays, narrative/rationale, and all
tooth IDs that will be replaced.
D5821 Interim partial denture (mandibular) Requires pre-authorization and x-rays, narrative/rationale, and all
tooth IDs that will be replaced.
17.6.8. Other Removable Prosthodontic Services

D6096 Remove broken implant retaining screw Requires pre-authorization with x-rays, quadrant/tooth ID and
narrative.
17.7. Prosthodontic (Fixed) Services
17.7.1. Other Fixed Partial Dentures

• The delivery/seating date of the complete denture and/or partial denture is the billing date of service.
D6985 Pediatric partial denture, fixed Requires pre-authorization with narrative, quadrant/arch and x-rays
and/or color photos.

• MCNA will not cover extractions of non-infected primary teeth when normal loss is imminent.
• Tooth ID must be included with all extractions and applicable codes.
17.8.1. Oral and Maxillofacial Surgery Services

D7111 Extraction, coronal remnants – primary tooth Requires tooth ID.

D7140 Extraction, erupted tooth or exposed root (elevation and/or Requires tooth ID. Includes incidental removal of a cyst or lesion
forceps removal) attached to the root.
D7210 Extraction, erupted tooth requiring removal of bone and/or Requires tooth ID. For general and pediatric dentists, requires pre-
sectioning of tooth, and including elevation of payment review. Must submit x-rays and clinical notes with claim.
mucoperiosteal flap if indicated
For oral surgeons, pre-payment review is required for tooth IDs 1, 16,
17, and 32. Must submit x-rays and clinical notes with claim.
D7220 Removal of impacted tooth - soft tissue Requires tooth ID. For general and pediatric dentists, requires pre-
payment review. Must submit x-rays and clinical notes with claim.
D7230 Removal of impacted tooth - partially bony Requires tooth ID. For general and pediatric dentists, requires pre-
D7240 Removal of impacted tooth - completely bony Requires tooth ID. For general and pediatric dentists, requires pre-
D7241 Removal of impacted tooth - completely bony, with unusual Requires tooth ID. Document unusual circumstance. This procedure
surgical complications code will only be authorized on a post-surgical basis. Please submit
preoperative x-ray(s) and clinical/operative notes outlining the
unusual surgical complications with the claim.
D7250 Removal of residual tooth roots (cutting procedure) Requires tooth ID. For general and pediatric dentists, requires pre-
17.8.2. Other Surgical Procedures

D7260 Oroantral fistula closure

D7261 Primary closure of a sinus perforation
D7270 Tooth re-implantation and/or stabilization of accidentally

evulsed or displaced tooth
D7280 Exposure of an unerupted tooth Requires pre-payment review. Must submit x-rays with claim.
D7283 Placement of device to facilitate eruption of impacted tooth Requires pre-payment review. Must submit x-rays with claim.
D7296 Corticotomy - one to three teeth or tooth spaces, per One (1) D7296 or D7297 per lifetime per patient per quadrant.
quadrant
D7297 Corticotomy - four or more teeth or tooth spaces, per One (1) D7296 or D7297 per lifetime per patient per quadrant.
quadrant
17.8.3. Alveoloplasty- Surgical Preparation of Ridge for Dentures

D7310 Alveoloplasty in conjunction with extractions - four or more One (1) D7310 per lifetime per patient per quadrant.
teeth or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions - one to One (1) D7320 per lifetime per patient per quadrant.
three teeth or tooth spaces, per quadrant
D7472 Removal of torus palatinus One (1) D7472 per lifetime per patient. Can only be billed for
preparation of complete denture.
D7473 Removal of torus mandibularis One (1) D7473 per lifetime per patient per quadrant (30 and 40). Can
only be billed for preparation of complete or partial lower denture.
17.8.4. Surgical Incision

D7510 Incision and drainage of abscess - intraoral soft tissue Not allowed with codes D7111 – D7250.
D7520 Incision and drainage of abscess - extraoral soft tissue Not allowed with codes D7111 – D7250.
17.8.5. Temporomandibular Joint (TMJ) Dislocation and Management of Other TMJ Dysfunctions
D7880 Occlusal orthotic device, by report Requires pre-authorization, arch, x-rays and/or color photos, and
narrative.
D7881 Occlusal orthotic device adjustment D7881 cannot be performed within the first 6 months after D7880.
Requires pre-payment review. Must submit narrative with claim.
17.8.6. Other Repair Procedures

D7970 Excision of hyperplastic tissue-per arch Not allowed on the same day of service as D7310 or D7320.
D7999 Unspecified oral surgery procedure, by report Requires pre-authorization with x-rays and or color photos, and
narrative.
17.9. Adjunctive General Services
17.9.1. Unclassified Treatment

D9110 Palliative treatment of dental pain – per visit Not allowed with any other services except radiographs and
emergency exam.
17.9.2. Anesthesia
• Intravenous/Non-Intravenous conscious sedation is limited to three (3) separate visits per 366 days, per
patient.
• Anesthesia codes will not be reimbursed unless billed with other covered services
• Failed sedations require submission of clinical notes with the claim and are subject to prepayment review.
• Florida Medicaid does not reimburse for the following:
o Local/regional anesthesia for restorative services, billed separately
o Sedation on the same date of service as behavior management
Units Number of Minutes
0 units 0 minutes through 7 minutes
1 unit 8 minutes through 22 minutes
D9222 Deep sedation/general anesthesia - first 15 minutes Requires pre-payment review. Must submit anesthesia time record,
including start and stop times, with claim.
Oral surgeons excluded from pre-payment review unless the

claim exceeds the combined 3-unit maximum of D9222 and
D9223.
D9223 Deep sedation/general anesthesia - each subsequent 15 Requires pre-payment review. Must submit anesthesia time record,
minutes including start and stop times, with claim.

D9223.
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis Not allowed on same date of service as D9222, D9223, D9239, or
D9243.
D9239 Intravenous moderate (conscious) sedation/analgesia – Requires pre-payment review. Must submit anesthesia time record,
first 15 minutes including start and stop times, with claim.

D9243.
D9243 Intravenous moderate (conscious) sedation/analgesia – Requires pre-payment review. Must submit anesthesia time record,
each subsequent 15 minute increment including start and stop times, with claim.

D9243.
D9248 Non - intravenous conscious sedation Limited to three (3) D9248 per year.
17.9.3. Professional Visits

D9310 Consultation - diagnostic service provided by dentist or

physician other than requesting dentist of physician
D9420 Hospital or ambulatory surgical center call Limited to one (1) D9420 per day, per patient, per provider, facility, or
group.
D9440 Office visit – after regularly scheduled hours Limited to two (2) D9440 per year per patient.
17.9.4. Miscellaneous Services

D9920 Behavior management, by report Limited to three (3) D9920 per year per patient. Behavior
management must be billed in conjunction with diagnostic, preventive
or treatment codes on the same date of service.
Medicaid does not reimburse for behavior management if:

• Billed routinely every time the patient visits the office; or
• Billed with either sedation or analgesia on the same date of
service.
D9999 Unspecified adjunctive procedure, by report Requires narrative/rationale.
17.9.5. Teledentistry
D9995 Teledentistry – synchronous; real-time encounter. Not reimbursed but must be included on any claim involving the use
of teledentistry for informational purposes.
D9996 Teledentistry – asynchronous; information stored and Not reimbursed but must be included on any claim involving the use
forwarded to dentist for subsequent review. of teledentistry for informational purposes.
17.10. Orthodontic Services

Services are limited to those circumstances where the enrollee’s condition creates a disability and impairs their
physical development. Maintenance visits are limited to up to 24 units within a 36-month period, including the
removal of the appliances and retainers at the end of treatment. Services will not be covered if services are for:
• Limited or interceptive treatment,
• Primarily cosmetic purposes, or
• Split phase treatment, with the exception for cleft palate cases*.
The member must be a good candidate for orthodontic treatment as assessed by the potential provider. The
member must exhibit a history of good oral hygiene, be under the care of a dentist for routine care and all
necessary dental care (i.e., prophylaxis, restorations, addressing any noted pathology, including receiving a
cleaning within the last six months) must be completed prior to submission of an orthodontic prior authorization
request. This approach is designed to lessen the occurrence of tooth decay and promote the best possible
outcome for the orthodontic treatment.
For a complete description of the orthodontic guidelines, see AHCA’s Medicaid Orthodontic Initial Assessment
Form in Section 19: Forms of this manual.
*Please do not submit cases involving craniofacial anomalies and/or cleft palates through the Provider Portal.
Instead, please send these types of cases directly to MCNA’s Case Management Department at
casemanagement@mcna.net.
17.10.1. Comprehensive Orthodontic Treatment

D8070 Comprehensive orthodontic treatment of the transitional Requires pre-authorization with arch, cephalometric x-ray with
dentition millimeter scale are required, panoramic x-ray, narrative, diagnostic
photographs, and completed orthodontic assessment form.
Diagnostic quality study models (or OrthoCad equivalent) are not

required, but will help to provide information of qualification of the
patient. Please note: instead of submitting physical study models
with a prior authorization request, providers are encouraged to
submit diagnostic quality digital images of the study models. Five
images (w/millimeter scale are preferred): 1) frontal view (with the
study models in centric occlusion) 2) right lateral view (with the study
models in centric occlusion) 3) left lateral view (with the study models
in centric occlusion) 4) occlusal view of the upper arch 5) occlusal
view of the lower arch. Diagnostic quality digital images of the study
models may be requested by the orthodontic clinical reviewer to help
in evaluating the request.
D8080 Comprehensive orthodontic treatment of the adolescent Requires pre-authorization with arch, cephalometric x-ray with
dentition millimeter scale are required, panoramic x-ray, narrative, diagnostic

D8090 Comprehensive orthodontic treatment of the adult dentition Requires pre-authorization with arch, cephalometric x-ray with
millimeter scale are required, panoramic x-ray, narrative, diagnostic

17.10.2. Minor Treatment to Control Harmful Habits

D8210 Removable appliance therapy Requires pre-authorization with arch, narrative/rationale, x-rays
D8220 Fixed appliance therapy Requires pre-authorization with arch, narrative/rationale, x-rays
17.10.3. Other Orthodontic Services

D8660 Pre-orthodontic treatment examination to monitor growth Requires models, cephalometric x-ray, panoramic x-ray, narrative,
and development diagnostic photographs, and completed orthodontic assessment
form.
D8670 Periodic orthodontic treatment visit Requires pre-authorization with models, cephalometric x-ray,
panoramic x-ray, narrative, diagnostic photographs, and completed
orthodontic assessment form.
D8680 Orthodontic retention (removal of appliances, construction Requires pre-authorization with arch and narrative/rationale
and placement of retainer(s))
D8703 Replacement of lost or broken retainer – maxillary Requires pre-authorization and narrative. One replacement retainer
per arch per lifetime.
D8704 Replacement of lost or broken retainer - mandibular Requires pre-authorization and narrative. One replacement retainer
per arch per lifetime.
D8999 Unspecified orthodontic procedure, by report Requires pre-authorization and narrative.
Section 19: Forms
18. Covered Services: Adults (21+)

Notes: Members are covered to see an Oral Surgeon. All other procedures not listed in this benefit schedule are
considered non-covered services.
Claims are denied if the procedure code is not compatible with TID or SID. Use the alpha characters to describe
tooth surfaces or any combination of surfaces. For SID designation on anterior teeth, use facial (F) and incisal (I).
For SID purposes, use buccal (B) and occlusal (O) designations for posterior teeth.
Each identified permanent tooth and each identified primary tooth has its own identifiable supernumerary number.
This developed system can be found in the Current Dental Terminology (CDT) published by the ADA.
Permanent Teeth Upper Arch
Tooth Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Super Number 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
Permanent Teeth Lower Arch

Tooth Number 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Super Number 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67
Primary Teeth Upper Arch

Tooth Number A B C D E F G H I J
Super Number AS BS CS DS ES FS GS HS IS JS
Primary Teeth Lower Arch

Tooth Number T S R Q P O N M L K
Super Number TS SS RS QS PS OS NS MS LS KS
Section 19: Forms
18.1. Diagnostic Services

D0140 Limited oral evaluation – problem focused Limited examinations (D0140) are not reimbursable on the same day
as codes D0120, D0150, D0190, D0191. Not to be used as follow-up
care.
D0150 Comprehensive oral evaluation Limited to once every three (3) years per provider, facility, or group.

• The fee for a comprehensive series of radiographic images mouth series x-ray (D0210) will be applied
when an office submits a combination of periapical x-rays, bitewing x-rays, or panoramic x-rays exceeding
the reimbursable value of the comprehensive series of radiographic images.
D0210 Intraoral – comprehensive series of radiographic images Limited to one (1) every three (3) years by the same provider, facility,
or group.
D0220 Intraoral – periapical first radiographic image Requires tooth ID.
D0230 Intraoral – periapical each radiographic image Requires tooth ID.
D0240 Intraoral – occlusal radiographic image Requires tooth ID.
D0330 Panoramic radiographic image Limited to one (1) every three (3) years by the same provider, facility,
or group.
18.2. Prosthodontic (Removable) Services
18.2.1. Complete Dentures (Including Routine Post Delivery Care)

• The delivery/seating date of the complete denture is the billing date of service.
D5110 Complete denture - maxillary Requires pre-authorization narrative/rationale and x-ray/ color
photos. One (1) D5110, D5211, or D5213 per lifetime, per patient.
D5120 Complete denture - mandibular Requires pre-authorization narrative/rationale and x-rays/ color
photos. One (1) D5120, D5212, or D5214 per lifetime, per patient.
Partial Dentures (Including Routine Post Delivery Care)

• The delivery/seating date of the complete denture and/or partial denture is the billing date of service.
D5211 Maxillary partial denture – resin base (including Requires pre-authorization and x-rays, narrative/rationale, and teeth
per patient.
D5212 Mandibular partial denture – resin base (including Requires pre-authorization and x-rays, narrative/rationale, and teeth
per patient.
D5213 Maxillary partial denture - cast metal framework with resin Requires pre-authorization and x-rays, narrative/rationale, and teeth
denture bases that will be replaced. One (1) D5110, D5211, or D5213 per lifetime,
per patient.
Section 19: Forms
D5214 Mandibular partial denture - case metal framework with Requires pre-authorization and x-rays, narrative/rationale, and teeth
resin denture bases that will be replaced. One (1) D5120, D5212, or D5214 per lifetime,
per patient.
18.2.2. Adjustments to Dentures

• Considered inclusive within six (6) months of seating of the denture.
D5410 Adjust complete denture - maxillary Limited to one (1) per 12 months.
D5411 Adjust complete denture - mandibular Limited to one (1) per 12 months.
D5421 Adjust partial denture - maxillary Limited to one (1) per 12 months.
D5422 Adjust partial denture - mandibular Limited to one (1) per 12 months.
18.2.3. Repairs to Complete Dentures

• Considered inclusive within six (6) months of seating of complete dentures.
D5511 Repair broken complete denture base, mandibular Limited to one (1) per 12 months.
D5512 Repair broken complete denture base, maxillary Limited to one (1) per 12 months.
D5520 Replace missing or broken teeth - complete denture (each Limited to one (1) per 12 months.
tooth)
18.2.4. Repairs to Partial Dentures

• Limited to one (1) per 12 months.
• Considered inclusive within six (6) months of seating of partial dentures.
D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary
D5621 Repair cast partial framework, mandibular
D5622 Repair cast partial framework, maxillary
D5630 Repair or replace broken retentive/clasping materials – per
tooth
D5640 Replace broken teeth - per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture – per tooth
18.2.5. Denture Reline Procedures

• Limited to one (1) per 12 months.
• Considered inclusive within six (6) months of seating of partial or complete dentures.
D5730 Reline complete maxillary denture (direct)

D5731 Reline complete mandibular denture (direct)
Section 19: Forms
D5740 Reline maxillary partial denture (direct)

D5741 Reline mandibular partial denture (direct)
D5750 Reline complete maxillary denture (indirect)
D5751 Reline complete mandibular denture (indirect)
D5760 Reline partial maxillary denture (indirect)
D5761 Reline mandibular partial denture (indirect)
D6096 Remove broken implant retaining screw Requires pre-authorization with x-rays, quadrant/TID and narrative.

D7140 Extraction, erupted tooth or exposed root (elevation and/or Includes incidental removal of a cyst or lesion attached to the root.
forceps removal)
18.3.2. Surgical Extractions

D7210 Extraction, erupted tooth requiring removal of bone and/or For general dentists, requires pre-payment review. Must submit x-
sectioning of tooth, and including elevation of rays and clinical notes with claim.
mucoperiosteal flap if indicated
D7220 Removal of impacted tooth - soft tissue For general dentists, requires pre-payment review. Must submit x-
rays and clinical notes with claim.
D7230 Removal of impacted tooth - partially bony For general dentists, requires pre-payment review. Must submit x-
D7240 Removal of impacted tooth - completely bony For general dentists, requires pre-payment review. Must submit x-
D7241 Removal of impacted tooth - completely bony, with unusual Document unusual circumstance. This procedure code will only be
surgical complications authorized on a post-surgical basis. Please submit preoperative x-
ray(s) and clinical/operative notes outlining the unusual surgical
complications with the claim.
D7250 Removal of residual tooth roots (cutting procedure) For general dentists, requires pre-payment review. Must submit x-
Section 19: Forms
18.3.3. Other Surgical Procedures

D7260 Oroantral l fistula closure

D7261 Primary closure of a sinus perforation
18.3.4. Alveoloplasty - Surgical Preparation of Ridge for Dentures

D7310 Alveoloplasty in conjunction with extractions - four or more One (1) D7310 per lifetime per patient per quadrant.
teeth or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions - one to One (1) D7320 per lifetime per patient per quadrant.
three teeth or tooth spaces, per quadrant
D7472 Removal of torus palatinus One (1) D7472 per lifetime per patient. Can only be billed for
preparation of dentures.
D7473 Removal of torus mandibularis One (1) D7473 per lifetime per patient per quadrant (30 and 40). Can
only be billed for preparation of complete and partial dentures.
18.3.5. Surgical Incision

D7510 Incision and drainage of abscess - intraoral soft tissue Not allowed with codes D7111 – D7250.
D7520 Incision and drainage of abscess - extraoral soft tissue Not allowed with codes D7111 – D7250.
18.3.6. Other Repair Procedures

D7970 Excision of hyperplastic tissue - per arch Not allowed on the same day of service as D7310 or D7320.
18.4. Adjunctive General Services
18.4.1. Anesthesia
• Intravenous/Non-Intravenous conscious sedation is limited to three (3) times per 366 days, per recipient.
• Florida Medicaid does not reimburse for the following:
o Local/regional anesthesia for restorative services, billed separately
o Sedation on the same date of service as behavior management
o Anesthesia codes will not be reimbursed unless billed with other covered services
o Failed sedations require submission of clinical notes with the claim and are subject to prepayment
review.
Units Number of Minutes
1 unit 8 minutes through 22 minutes
Section 19: Forms
D9222 Deep sedation/general anesthesia - first 15 minutes Requires pre-payment review. Must submit anesthesia time record,
including start and stop times, with claim.

D9223.
D9223 Deep sedation/general anesthesia - each subsequent 15 Requires pre-payment review. Must submit anesthesia time record,
minute increment including start and stop times, with claim.

D9223.
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis Not allowed on same date of service as D9222, D9223, D9239, or
D9243.
D9239 Intravenous moderate (conscious) sedation/analgesia - first Requires pre-payment review. Must submit anesthesia time record,
15 minutes including start and stop times, with claim.

D9243.
D9243 Intravenous moderate (conscious) sedation/analgesia - Requires pre-payment review. Must submit anesthesia time record,
each subsequent 15 minute increment including start and stop times, with claim.

D9243.
D9248 Non-intravenous conscious sedation Limited to three (3) D9248 per year.
18.4.2. Professional Visits

D9420 Hospital or ambulatory surgical center call Limited to one (1) D9420 per day, per patient, per provider, facility, or
group.
Section 19: Forms
18.4.3. Teledentistry
D9995 Teledentistry – synchronous; real-time encounter. Not reimbursed but must be included on any claim involving the use
of teledentistry for informational purposes.
D9996 Teledentistry – asynchronous; information stored and Not reimbursed but must be included on any claim involving the use
forwarded to dentist for subsequent review. of teledentistry for informational purposes.
18.5. Expanded Benefits for Adult Medicaid Enrollees (21+) and Pregnant Women (21+)
Pregnant members are eligible for additional exams, dental screenings, x-rays, cleanings, fluoride, oral hygiene
instructions, deep cleanings, and general services that are medically necessary.

D0120 Periodic oral evaluation – established patient Limited to one (1) per 6 months per patient. One (1) of D0120 or
D0150 per 6 months per provider, facility, or group.
D0190 Screening of a patient (DOH or FQHC Only) Limited to one (1) per 6 months.
D0191 Assessment of a patient (DOH or FQHC Only) Limited to one (1) per 6 months.

The fee for a comprehensive series of radiographic images mouth series x-ray (D0210) will be applied
when an office submits a combination of periapical x-rays, bitewing x-rays, or panoramic x-rays exceeding
the reimbursable value of the comprehensive series of radiographic images.
D0250 Extra-oral - 2D projection radiographic image created using a stationary

radiation source, and detector
D0251 Extra-oral posterior dental radiographic image
D0270 Bitewing - single radiographic image Limited to one (1) D0270 per 6 months.
D0272 Bitewings - two radiographic images Limited to one (1) D0272 per 6 months.
D0274 Bitewings - four radiographic images Limited to one (1) D0274 per 6 months.
18.5.3. Preventive Services

D1110 Prophylaxis - adult Limited to one D1110 or D4346 per 6-month

period.
D1206 Topical application of fluoride varnish Limited to one (1) D1206 or D1208 every 6
months, per patient.
D1208 Topical application of fluoride - excluding Limited to one (1) D1206 or D1208 every 6
varnish months, per patient.
D1330 Oral hygiene instructions Limited to one (1) every 6 months.
D1351 Sealant - per tooth Limited to once per three (3) years, per
tooth. First, second, and third permanent
molars only – 1, 2, 3, 14, 15, 16, 17, 18, 19,
30, 31, 32.
D1354 Application of caries arresting medicament - Limited to once per tooth, every 6 months.
per tooth Requires tooth ID.
Section 19: Forms
18.5.4. Restorative Services

• One (1) restoration every three (3) years per tooth number or letter per surface.
D2140 Amalgam - one (1) surface, primary or permanent

D2150 Amalgam - two (2) surfaces, primary or permanent
D2160 Amalgam - three (3) surfaces, primary or permanent
D2161 Amalgam - four (4) or more surfaces, primary or permanent
D2330 Resin-based composite - one (1) surface, anterior
D2331 Resin-based composite - two (2) surfaces, anterior
D2332 Resin-based composite - three (3) surfaces, anterior
D2335 Resin-based composite - four (4) or more surfaces involving incisal
angle (anterior)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite - one (1) surface, posterior
D2392 Resin-based composite - two (2) surfaces, posterior
D2393 Resin-based composite - three (3) surfaces, posterior
D2940 Protective restoration
18.5.5. Periodontal Services

• Nonsurgical periodontal services will not be reimbursed with a prophylaxis on the same date of service.
D4341 Periodontal scaling and root planing - four (4) or more teeth One (1) D4341, D4342 per 24 months per patient per quadrant. Not
per quadrant allowed on same date of service as D1110, D1120, D4346, or
D4355. Must indicate quadrant on claim.
D4342 Periodontal scaling and root planing - one (1) to three (3) One (1) D4341, D4342 per 24 months per patient per quadrant. Not
teeth per quadrant allowed on same date of service as D1110, D1120, D4346, or
D4355. Must indicate quadrant on claim.
D4346 Scaling in presence of generalized moderate or severe One (1) D1110 or D4346 per 6 months per patient.
gingival inflammation - full mouth, after oral evaluation
D4355 Full mouth debridement to enable a comprehensive Limited to one (1) D4355 per year. Not allowed for 12 months
periodontal evaluation and diagnosis on a subsequent visit following D1110, D1120, or any 4000-series code.

D7111 Extraction, coronal remnants – primary tooth Requires tooth ID. Limited to one (1) D7111 per tooth per lifetime.
Section 19: Forms
D7270 Tooth re-implantation and/or stabilization of accidentally Requires tooth ID. Limited to one (1) D7270 per lifetime per patient
evulsed or displaced tooth per tooth.
18.5.7. Adjunctive General Services

D9110 Palliative treatment of dental pain – per visit Not allowed with any other services except radiographs and
emergency exam.
D9310 Consultation - diagnostic service provided by dentist or Limited to one (1) D9310 per year per patient.
physician other than requesting dentist or physician
D9440 Office visit – after regularly scheduled hours Limited to two (2) D9440 per year per patient.
D9920 Behavior management, by report Limited to three (3) D9920 per year per patient. Behavior
management must be billed in conjunction with diagnostic, preventive
or treatment codes on the same date of service.
Medicaid does not reimburse for behavior management if:

• Billed routinely every time the patient visits the office; or
• Billed with either sedation or analgesia on the same date of
service.
18.6. Other Expanded Adult Dental Services

D0411 HbA1c in-office point of service testing Limited to one (1) per year.
D0999 Unspecified diagnostic procedure, by report For MCNA, this is an office acclimation visit for Adults with
Intellectual Disabilities. Limited to one (1) D0999 per patient per
facility. Must indicate special needs on claim form in Box 35.
Section 19: Forms
19. Forms
19.1. Medicaid Orthodontic Initial Assessment Form
APPENDIX A
MEDICAID ORTHODONTIC INITIAL ASSESSMENT FORM (IAF)
You will need this scoresheet and a disposable ruler (or a Boley Gauge)
Name: I. D. Number:
Conditions: HLD Score

1. Cleft palate deformities
(Indicate an “X” if present and score no further)
2. Deep impinging overbite. When lower incisors are destroying the soft tissue
3. Crossbite of individual anterior teeth. When destruction of soft tissue is present

4. Severe traumatic deviations. (Attach description of condition. For example, loss of a premaxilla
segment by burns or accident, the result of osteomyelitis or other gross pathology)
5A. Overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm
with reported masticatory and speech difficulties.
5B. Overjet in mm
6. Overbite in mm
7. Mandibular protrusion in mm x 5=
8. Open bite in mm x 4=
IF BOTH ANTERIOR CROWDING AND ECTOPIC ERUPTION ARE PRESENT IN THE ANTERIOR PORTION
OF THE MOUTH, SCORE ONLY THE MOST SEVERE CONDITION. DO NOT SCORE BOTH CONDITIONS.
9. Ectopic eruption (Count each tooth, excluding third molars). x 3=
10. Anterior crowding (Score one point for MAXILLA and one point for MANDIBLE,
two points for maximum anterior crowding). x 5=
11. Labio-Lingual spread in mm
12. Posterior unilateral crossbite (must involve two or more adjacent teeth,
one of which must be a molar) Score 4
Total Score
Section 19: Forms
Dental Services Coverage and Limitations Handbook
Patient name: _Medicaid I.D. #
Please describe these and any other problems:
Please describe tentative treatment plan:
Use additional sheets as required.
Date Provider’s signature

For Medicaid use
Patient does not meet Medicaid criteria for “most severely handicapped”
Patient not eligible
Send additional materials, as per handbook
Consultant Date_
AHCA-Med Serv Form 013, January 2006
Section 19: Forms

,
Appendix A continued
How to Score the Initial Assessment Form

Cleft Palate – Submit a cleft palate case in the mixed dentition only if you can justify in a narrative why there
should be treatment before the client is in full dentition.
Severe Traumatic Deviation – Refers to facial accidents only. Points cannot be awarded for congenital deformity.
It does not include traumatic occlusions for crossbites.
Overjet in Millimeters – Score the case exactly as measured, then subtract 2mm (considered the norm)
and enter the difference as the score.
Overbite in Millimeters – Score the case exactly as measured, then subtract 3mm (considered the norm) and
enter the difference as the score. This would be double counting.
Mandibular Protrusion in Millimeters – Score the case by measurement in mm by the distance from the labial
surface of the mandibular incisors to the labial surface of the maxillary incisor. Do not score both overbite and open
bite.
Open Bite in Millimeters – Score the case exactly as measured. Measurement should be recorded from the
“line of occlusion” of the permanent teeth-not from ectopically erupted teeth in the anterior segment. Caution is
advised in undertaking treatment of open bites in older teenagers, because of the frequency of relapse.
Ectopic Eruption – An unusual pattern of eruption, such as high labial cuspids or teeth that are grossly out of the
long axis of the alveolar ridge. Do not include (score) teeth from an arch if that arch is to be counted in the following
category of “Anterior crowding.” For each arch, you may score either the ectopic eruption or anterior crowding but
not both.
Anterior Crowding – Anterior teeth that require extractions as a prerequisite to gain adequate room to treat the
case. If the arch expansion is to be implemented as an alternative to extraction, provide an estimated number of
appointments required to attain adequate stabilization. Arch length insufficiency must exceed 3.5 mm to score for
crowding on any arch. Mild rotations that may react favorably to stripping or moderate expansion procedures are
not to be scored as “crowded.”
Labio-Lingual Spread in millimeters –The measurement of the lower incisors in millimeters in the deviation
from the normal arch of the lower teeth.
Providers should be conservative in scoring. Liberal scoring will not be helpful in the evaluation and approval of the
case. The case must be considered dysfunctional and have a minimum of 26 points on the IAF to qualify for any
orthodontic care other than crossbite correction.
The intent of the program is to provide orthodontic care to recipients with handicapping malocclusion to improve
function. Although aesthetics is an important part of self-esteem, services that are primarily for aesthetics are not
within the scope of benefits of this program.
If attaining a qualifying score of 26 points is uncertain, provide a brief narrative when submitting the case. The narrative
may reduce the time necessary to gain final approval and reduce shipping costs incurred to resubmit records.
Section 19: Forms
Directions For Using The Handicapping Labio-Lingual Deviation (HLD) Index
Instructions for HLD Index Measurements
Procedure:
1. Position the patient’s teeth in centric occlusion.

2. Record all measurements in the order given and round off to the nearest millimeter (mm).
3. Enter score “0” if condition is absent.
4. The use of a recorder is recommended.
Conditions:
1. Cleft palate deformities---automatic qualification; however, if the deformity cannot be demonstrated on

the study mode, the condition must be diagnosed by properly credentialed experts and that diagnosis
must be supported by documentation. If present, enter an “X” and score no further.
2. Deep impinging overbite---tissue destruction of the palate must be clearly visible in mouth.
On study models, the lower teeth must be clearly touching the palate and there must be clear evidence
of damage visible on the submitted models; touching or slight indentations do not qualify. If present,
enter an “X” and score no further.
3. Crossbite of individual anterior teeth---destruction of soft tissue must be clearly visible in the mouth and
reproducible and visible on the study models. A minimum of 1.5mm of tissue recession must be
evident to qualify as soft tissue destruction in anterior crossbite cases. If present, enter an “X” and
score no further.
4. Severe traumatic deviations---these might include, for example, loss of premaxillary segment by burns or
accident, the result of osteomyelitis, or other gross pathology. Traumatic deviation does not mean loss
of anterior teeth due to gross destruction or evulsion. If present, enter an “X” and score no further.
5. Overjet---this is recorded with the patient’s teeth in centric occlusion and is measured from the labial
surface of a lower incisor to the labial surface of an upper central incisor. Measure parallel to the
occlusal plane. Do not use the upper lateral incisors or cuspids. The measurement may apply to only
one tooth if it is severely protrusive. Reverse overjet may be measured in the same manner. Do not
record overjet and mandibular protrusion (reverse overjet) on the same patient. If the overjet is greater
than 9mm or reverse overjet is greater than 3.5mm, enter an “X” and score no further. Otherwise, enter
the measurement in mm x
1.
6. Overbite---a pencil mark on the tooth indicating the extent of the overlap assists in making this
measurement. Hold the pencil parallel to the occlusal plane when marking and use the incisal edge of
one of the upper central incisors. Do not use the upper lateral incisors or cuspids. The measurement
is done on the lower incisor from the incisal edge to the pencil mark. “Reverse” overbite may exist and
should be measured on an upper central incisor- from the incisal edge to the pencil mark. Do not
record overbite and open bite on the same patient. Enter the measurement in mm x 1.
7. Mandibular (dental) protrusion or reverse overjet---measured from the labial surface of a lower incisor to
the labial surface of an upper central incisor. Mandibular incisors in crossbite do not count as
mandibular (dental) protrusion or reverse overjet. Skeletal mandibular protrusion must be present. Do
not use the upper lateral incisors or cuspids for this measurement. Do not record mandibular protrusion
(reverse overjet) and overjet on the same patient. The measurement in millimeters is entered on the
scoresheet and multiplied by five (5).
Section 19: Forms
Directions For Using The Handicapping Labio-Lingual Deviation (HLD) Index, continued
8. Open bite---measured from the incisal edge of an upper central incisor to the incisal edge of a lower
incisor. Do not use the upper lateral incisors or cuspids for this measurement. In some situations, one
has to make an approximation by measuring perpendicular to the occlusal plane as illustrated in Fig. 1.
Do not record overbite and open bite on the same patient. The measurement in millimeters is entered on
the scoresheet and multiplied by four (4).
9. Ectopic eruption---count each tooth excluding third molars. Enter the number of teeth on the scoresheet
and multiply by three (3). If condition No. 10, anterior crowding, is also present with an ectopic eruption
in the anterior portion of the mouth, score only the most severe condition ( the condition represented by
the most points). Do not score both conditions.
10. Anterior crowding---anterior arch length insufficiency must exceed 3.5 mm. Mild rotations that may react
favorably to stripping or mild expansion procedures are not to be scored as crowded. Enter five (5)
points for maxillary arch with anterior crowding and (5) points for mandibular arch with anterior crowding.
If condition. No.9, ectopic eruption is also present in the anterior portion of the mouth, score only the
most severe condition (the condition represented by the most points). Do not score both conditions.
11. Labiolingual spread---use a disposable ruler (or a Boley gauge) to determine the extent of deviation from
a normal arch. W here there is only a protruded or lingually displaced anterior tooth, the measurement
should be made from the incisal edge of that tooth to a line representing the normal arch line.
Otherwise, the total distance between the most protruded tooth and the most lingually displaced
adjacent anterior tooth. In the event that multiple anterior crowding is observed, all deviations should be
measured for labiolingual spread but only the most severe individual measurement should be entered
on the scoresheet. Enter the measurement in millimeters on the scoresheet.
12. Posterior unilateral crossbite---this condition involves two or more adjacent teeth, one of which must be a
molar. The crossbite must be one in which the two maxillary posterior teeth involved may either be both
palatal or both completely buccal in relation to the mandibular posterior teeth. The presence of posterior
unilateral crossbite is indicated by a score of four (4) on the scoresheet.
Section 19: Forms
19.2. Other Forms

The following forms can be downloaded using the links provided.
• Member Outreach Form
o http://forms.mcna.net/fl-member-outreach
• Member Oral Health Risk Assessment
o https://docs.mcna.net/forms/member-oha
• Provider Appeal Form
o http://forms.mcna.net/fl-provider-appeal
• Orthodontic Continuation of Care Form
o http://forms.mcna.net/fl-ortho-coc
• Overpayment and Recoupment Form
o https://docs.mcna.net/forms/overpayment-recoup

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Florida Medicaid

2. MCNA Contact Information ................................................................................................................................. 9

3. Revision History ................................................................................................................................................. 10

4. Program Overview .............................................................................................................................................. 14

5. Administration Overview ................................................................................................................................... 15

6. Provider Responsibilities .................................................................................................................................. 18

The Department of Health and Human ................................................................................................................. 22

6.11. MCNA’s Zero Tolerance Policy on Retaliation ............................................................................................ 23

7. Online Provider Portal ....................................................................................................................................... 26

8. Claims and Payments ........................................................................................................................................ 27

9. Provider Complaints and Appeals .................................................................................................................... 31

10. Member Services .............................................................................................................................................. 33

11. Utilization Management ................................................................................................................................... 38

12. Treatment .......................................................................................................................................................... 41

13. Quality Improvement ........................................................................................................................................ 44

14. Office Policies and Procedures ...................................................................................................................... 51

15. Dental Services ................................................................................................................................................. 55

15.7. Oral and Maxillofacial Surgery Services ...................................................................................................... 57

16. Dental Guidelines ............................................................................................................................................. 58

17. Covered Services: Children (0-20) .................................................................................................................. 67

17.10. Orthodontic Services ................................................................................................................................. 81

18. Covered Services: Adults (21+) ...................................................................................................................... 83

19. Forms ................................................................................................................................................................. 92

2. MCNA Contact Information

2.1. Member Services and Eligibility Verification

2.2. Automated Eligibility Verification

2.3. Provider Hotline

2.5. Utilization Management (Pre-Authorizations)

2.6. Provider Portal Helpdesk

2.7. MCNA Hotlines

2.8. Corporate Contact Information

1.16 5/19/2023 Throughout document: Shaded covered services sections by population

1.15 12/30/2022 Updated 16.4.3 – Added D2928 description

Updated 18.1.2 - Updated D0210, D0220, D0230, and D0330 limitations

1.14 10/01/2022 Updated Section 2.8 – Updated Corporate Mailing Address

D2331, D2332, D2335, D2920, D2950, D3310, D3320, D3330,

1.11 06/2020 Page 10 - Updated Credentialing Fax Number: 954-628-3349

Adult Covered Services:

Updated requirements for D9230.

Changed the following in the Covered Services for Children (0-20):

Changed the following in the Covered Services for Adults (21+):

Children’s Covered Services:

Adult Covered Services:

1.3 12/2018 Update to limitation for D0150 for adult members.

1.2 11/2018 Updates to expanded benefits for adults. Updates to pre-authorization

1.0 11/2018 Initial version.

5.1. Member Enrollment

5.2. Member ID Card

5.3. Choosing a Primary Dental Provider

5.4. Member Disenrollment

5.5. Changes in Provider and Demographic Information

5.6. Change in Location

5.7. Release for Ethical Reasons

5.8. Member Dismissals from PDP Practices

5.9. Termination of Dental Contract

6.1. Primary Dental Providers

6.2. First Dental Homes

6.3. Special Needs Dental Homes