FAIR HEARINGS GUIDE

BACKGROUND:
Each year, thousands of children are unfairly denied treatment by MassHealth for Medically Necessary Orthodontic Care (MNOC).

While the law is on the side of the children, the bad actors at MassHealth violate the law and separate children from their rights.

MOMA, led by Dr. Mouhab Z. Rizkallah, President, fights every day for these needy children.

UNDERSTANDING AN “UNFAIR” DENIAL:
The denial for orthodontic coverage begins when a MassHealth Orthodontist submits a case for coverage and the DentaQuest reviewer denies the case by “overlooking” the need for coverage.  These oversight errors occur as much as 62% of the time and were once corrected using a method called “Peer Review.”
THE OLD PEER REVIEW PROCESS:
A Peer Review is a 10 minute phone call in which a child’s orthodontist calls the DentaQuest orthodontist that denied the child.  The child’s orthodontist shows the DentaQuest orthodontist the errors in the denial.  The child is usually approved after that call (62% of the time).

Dr. Mouhab Rizkallah has conducted numerous Peer Reviews of unfairly denied cases with DentaQuest, and the DentaQuest consultants admit 62% of the time that they incorrectly denied the child treatment (read that again).  Peer Reviews, therefore, correct 62% of denial errors by DentaQuest Orthodontists.

While you may think that such a high failure rate by DentaQuest Orthodontists would cause MassHealth to “crack down” on DentaQuest to improve quality control, you would be wrong.  MassHealth and its bad actors have actually done the opposite.  They have eliminated Peer Reviews altogether (in 2020)!

WHY ELIMINATE PEER REVIEWS WHEN THEY FIX 62% OF DENTAQUEST ERRORS?:
Of course, there is no legitimate reason to stop correcting DentaQuest errors.

There can only be a corrupt reason.  Go to “Why Delta Dental Should Not Run MassHealth“ for more insight into this corruption.

With Peer Reviews gone, what option is left to a child when their orthodontist can’t make a phone call to fight for the child?

The answer is the “Fair Hearings” process.  A process that is not fair.

THE FAIR HEARINGS PROCESS:
If your child needs orthodontic treatment, and you have been unfairly denied, you need to:

  • Fill out this form (Fair Hearings Form) and fax it to 617-887-8797 within 30 days.
    • If you don’t have a fax machine, that is unfair (they don’t accept emails).
    • If you can, have your orthodontist fax it in for you.
  • Wait for a response with a date for you to attend the hearing.
  • Go to the hearing on the date and time they scheduled for you.
  • Listen to a MassHealth representative (such as Dr. Harold Kaplan) misrepresent the orthodontic regulations to a hearing officer who knows very little about teeth.
  • Try to argue with Dr. Kaplan (even though you don’t know how to) about the regulations so you can convince the hearing officer that he/she should approve your child.
  • Wait 90 days for the hearing officer’s response, which is usually a denial.
  • If you want to appeal the denial, you need to sue MassHealth in superior court within 30 days of the denial.

Unfortunately, there is absolutely nothing fair about this process.  Even doctors do not know how to effectively argue with Dr. Kaplan about the regulations.  You need to be very knowledgeable to do this.

Click on the files below to hear audio footage of Dr. Mouhab Z. Rizkallah arguing with Dr. Kaplan for a tutorial on how to argue at the Fair Hearing.

CASE 1:  COMING SOON

CASE 2:  COMING SOON

CASE 3:  COMING SOON

CASE 4:  COMING SOON

STEPS AT FAIR HEARING TO DEFEND YOUR CHILD:

STEP 1:  SHOWING MEDICAL NECESSITY
Your child will get MassHealth Coverage if he/she meets the standards of Medical Necessity.

DOCTOR FORM:
We welcome orthodontists to use this form (Doctor MassHealth Orthodontists – Medical Necessity Form) to help their patients.

PARENT FORM:
We welcome parents to use this form (Parent Form – Medically Necessary Orthodontic Care) to help their kids.

Fill Out the Blank Form and fax it with your appeal request.

STEP 2:  ASK YOUR ORTHODONTIST TO ACCOMPANY YOU
Your community likely has at least one orthodontists that takes MassHealth, and is probably the orthodontist you chose to work with.  So ask that orthodontist to join you at the Fair Hearings session.  Do not be disappointed if they cannot join you.  Most orthodontists cannot make it to the hearings (which is apparently what MassHealth wants, since they eliminated the orthodontist’s access to Peer Reviews).

If your orthodontist cannot join you, contact us at contactus@masshealth-orthodontists.org.  We will connect you with someone to join you.

STEP 3:  MAKE SURE YOUR ORTHODONTIST HAS THE MOMA APPENDIX PACKAGE
If you are lucky enough to get your orthodontist to go to the hearing, make sure they have the MOMA Appendix Package that was produced by Dr. Mouhab Z. Rizkallah.