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Dental Provider Credentialing 101: Application Process & Insurance Inquiries

Last week, I gave a full rundown of dental provider credentialing basics and outlined initial steps to get you started and make a confident decision to provide in-network or out-of-network patient care.

There are often two categories aligned with the dental credentialing process when establishing or joining a dental practice – (1) you may already be an in-network provider from a previous dental office or (2) you’re beginning the process from scratch. If you’re already an in-network provider, find out who you’re in-network with and the process is simple – it’s a matter of updating your practice’s address and new tax ID number, usually by completing an update form specific to each provider.

If you’re starting from scratch with the dental credentialing process, completion of a full application is necessary. Several states have a universal dental credentialing application using CAQH ProView, which requires an in-depth look at several documents. A full list of documents and identifiers for submission include:

  • National Provider Identification (NPI) number – An NPI number can be applied for online and is cost-free.
  • Dental license for the state you practice in.
  • Proof of malpractice insurance – Submit the page of the policy that outlines the length of time and amount of coverage you have.
  • DEA certificate – This is received from the federal government to prescribe medication. It’s important to password protect this document.
  • Certificate or diploma for a specialized degree – If you’re a specialist (i.e. orthodontics) you will need to provide proof of completing the specialization.
  • Additional board certifications (i.e. pediatric board certified).
  • W-9 form – This documentation reports your income to the federal government and could be different per dental practice you are employed by. You might need more than one W-9; it needs to belong to whoever is receiving the check.
  • Professional references – The CAQH application requires professional references (i.e. colleagues), but often are not actually contacted for application approval.

The best place to start and guide your application is your professional resume and personal information records (SSN, date of birth, etc.). Once you’ve completed and submitted your application, you’re ready to start reaching out to the dental insurance companies and begin making inquiries.

A RoadMap for Dental Credentialing Inquiries with Insurance Companies

  1. Visit the insurance company’s website. There is a section specifically for providers (i.e. ‘join our network’), which is where you’ll submit the initial credentialing inquiry.
    • Helpful tip: It’s smart to create a generical email address just for credentialing to help manage the credentialing process and documentation management.
  2. After the initial inquiry, the insurance company will send you a contract to review and sign (but often with no fee schedule).
  3. Ask the insurance company for their fees schedule, as well as their electronic funds transfer paper work to begin the process of account setup (you’ll need a voided check).
  4. After reviewing the insurance fees schedule, it’s time to negotiate. Insurance companies never offer their best rates up front, but will usually negotiate up to 20 codes. If you’re a specialist or live an underserved area, you will often have more leverage to negotiate.
  5. Pay attention to your most commonly billed codes (i.e. exam, filling, including amalgam, crown codes, and denture codes) and negotiate higher fees for these more highly used codes. Insurance companies will go back in forth no more than 2-3 times to settle on a fees schedule.
  6. Be sure to review and negotiate downgrade clause codes. Dental insurance companies often have fee loopholes around downgrade coverage. For example, a white filling is performed on a patient and the insurance has 80% coverage for white fillings, but the said fee policy has a downgrade clause attached (which can be buried in documentation), and the insurance company pays 80% coverage for only silver fillings. The patient will not receive the expected coverage due to this downgrade clause.
  7. Always set up direct contracts with companies that negotiate. If you do set up a direct contract, always make sure to opt out of the third-party fee schedule, so the insurance company uses the higher fees schedule (which is typically lower when a third-party firm is involved).
  8. Consider working with a third-party credentialing firm to assist with fee negotiation and management. Third-party firms can often help negotiate higher fees, but will likely only contract the work if you agree to an added paid service (i.e. using their claim service, etc.)

One of the top reasons I’ve seen for frustration and burnout among dentists is the exhaustive amount of time that can be required for credentialing and fees schedule setup and management. Dentists often reach a point to make the decision to join a corporate dental practice or engage outside dental practice management expertise if they want to maintain their sole practice. What has your experience been with dental provider credentialing?

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