Complaints/Grievances and Appeals

What should I do if I have a complaint?

We want to help. If you have a complaint, please call us toll-free at 1-855-691-6262 to speak to a Member Advocate. You can also submit your complaint in writing to:

You may also download the How to Submit a Complaint Flyer for more information about the process.

Can someone help me file my complaint?

Yes! An MCNA Member Advocate can help you file your complaint. Most of the time we can help you right away. Call 1-855-691-6262 to talk to an MCNA Member Advocate about your complaint. You may call at any time during the complaint process to check the status of your complaint.

Can I file a complaint with anyone else?

Medicaid Members

If you wish to file a complaint after going through MCNA's process, you can do one of the following:

• Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free)

• Online: https://hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman

• Fax: 1-888-780-8099 (toll-free)

• Mail:

CHIP Members

If you still wish to file a complaint after going through MCNA's process, you may file a complaint with the Texas Department of Insurance by phone at 1-800-252-3439, or by mail at:

What should I do if I have an appeal?

If you are not happy with MCNA's decision to deny or limit services requested by your dentist, please call us toll-free at 1-855-691-6262 to speak to a Member Advocate. When you call, we will explain what happens during the appeal process. You can file your appeal verbally when you call. You can also choose to send us a written appeal. If you would like to write your appeal, we will tell you how and send you any forms you may need to complete your appeal. You can send your written appeal to:

Can someone help me file my appeal?

Yes! An MCNA Member Advocate can help you file your appeal. Most of the time we can help you right away. Call the MCNA Member Hotline at 1-855-691-6262 to ask a Member Advocate for help with filing an appeal. You may call the Member Hotline at any time during the appeal process to check the status of your appeal.

How quickly are appeals resolved?

Standard appeals are resolved within 30 days. You can ask for an emergency appeal when you don't have time to wait for a standard appeal, such as when your child's life or health is in danger. Emergency appeals are resolved within 3 days. If MCNA decides your appeal does not meet the requirements to be expedited, your appeal will go through the standard appeal process. Our Member Advocates will guide you through this process.

What if I'm still not happy?

Medicaid Members

External Medicaid Review

If you, as a member of the dental plan, disagree with MCNA's internal appeal decision, you have the right to ask for External Medical Review with a State Fair Hearing. An External Medical Review is an optional, extra step you can take to get your case reviewed for free before your State Fair Hearing. You, your parent, your authorized representative, or your legally authorized representative (LAR) must ask for the External Medical Review within 120 days of the date MCNA mails the letter with the decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. You, your parent, your representative, or your LAR can ask for an External Medical Review in these ways:

• Call MCNA at 1-855-691-6262.

• Email MCNA at ga@mcna.net.

• Fill out the "State Fair Hearing and External Medical Review Request Form" that came with the internal appeal decision letter from MCNA. You can also download a copy of the form. Fax to MCNA at 1-954-628-3330 or mail to:

If you have questions about the External Medical Review Process or want to check on the status of an External Medical Review request we can help. Call MCNA toll-free at 1-855-691-6262. You can also learn more about the External Medical Review Process in MCNA's Medicaid Member Handbook.

State Fair Hearing

You have the right to ask for a State Fair Hearing. You must first exhaust MCNA's appeal process. In a State Fair Hearing, you may name someone to represent you (such as a doctor or other medical provider). You must ask for a State Fair Hearing within 120 days of the date on the original decision letter from MCNA. To make a request, you may write a letter that includes the name of your representative and send it to:

You can also ask for a State Fair Hearing by calling MCNA toll-free at 1-855-691-6262. Call this number at any time to ask questions or check the status of a State Fair Hearing.

Once you ask for the State Fair Hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most State Fair Hearings are held by telephone. The Texas Health and Human Services Commission will give you a final decision within 90 days from the hearing.

CHIP Members

If you are not happy with MCNA's decision to deny your appeal based on medical necessity, you can request a review of your case by an Independent Review Organization (IRO). An Independent Review Organization (IRO) is an organization that will review your appeal and decides if the services we denied or limited are medically necessary. The IRO has no connection to us or the decisions made by us to deny or limit services. They will make their decision based on certain rules. We must pay the cost of the external review conducted by IRO. MCNA must abide by the IRO's decision and carry out its instructions. You can call our Member Hotline toll-free at 1-855-691-6262 if you have any questions about the independent review process.

To ask for an IRO, you can fill out the "Request for a Review by an IRO" form. This form was sent with the MCNA appeal decision letter. You will have 120 days from the day you get our decision letter to send the form back to us. If you do not file your request for an external independent review with 120 days, it cannot be reviewed. When we get your completed form, we will tell the IRO about your request within 3 days. If you need help filling out the IRO form, please call our Member Hotline toll-free at 1-855-691-6262. An MCNA representative will be happy to help you.

Send your written request by email to ga@mcna.net, by fax to 1-954-628-3330, or by postal mail to:

Where can I find forms to use for a complaint or appeal?

You can download and print a Complaint Form, Appeal Form (CHIP), or Appeal Form (Medicaid). Learn more about Medicaid complaints and appeals in your Member Handbook. Texas Medicaid members will also find more information about the State Fair Hearing process.