05/01/2013

Have correct address on file with contracted plans

By Ann Milar, CDA dental benefits analyst

No matter how sophisticated and “smart” our computers and cellphones have become for communicating, it is still unnerving to open a letter (written, not emailed) and find unwelcome news in your mailbox. The latest piece of disturbing news for a few hundred California dentists was the letter they received from Delta Dental of California stating they had been terminated as participating providers as a result of failing to submit their recredentialing paperwork on time. 

For many of these dentists, this was the first time they received any information referencing recredentialing, so the news was a bit of a shock.  Some offices started receiving telephone calls from their patients stating they had received payment from Delta (instead of the dentist) before they even learned that they had been dropped from the network. 

What happened here?  After two weeks, some tears of frustration from dentists and several emails and telephone calls later, it was discovered that there were a few instances where the dental office and dentist overlooked Delta’s multiple requests for recredentialing paperwork.  For the most part, many of the offices had the wrong address on file with Delta and all of their paperwork went to a bad address.  Based on what we’ve learned to date, it looks like many of the dentists CDA worked with were able to be reinstated as providers without having to re-contract with Delta.  Good news, right?

Absolutely!  This recredentialing issue does illustrate the importance of ensuring all dental offices have the correct address on file with their contracted plans.  This will ensure that the offices receive necessary credentialing paperwork, tax documents and other written communication from plans in a timely manner.  Just as dentists need to renew their licenses with the dental board every two years, Knox-Keene licensed dental plans are obligated to recredential their providers every three years.  What does that mean for dentists contracted with dental plans? It means that every three years any dental plans you may be contracted with will request that you complete paperwork to verify your licensure and certification.  Similarly to when you first contracted with a dental plan, you may be asked to provide a list of documents (including license verification, certificate of liability insurance, a DEA or Controlled Substance Certificate, etc.) and then attest to your professional history by answering written questions.  So while you may have been a contracted provider with a plan for 20 years, plans are being audited and fined for not credentialing providers as they are legally required to do so, hence the more recent waves of recredentialing by Delta and other plans.

Most plans begin notifying their providers up to six months prior to the credentialing expiration date with written communication and follow-up telephone calls.  If a provider fails to provide the necessary documentation to the plan, the plan exercises its right to terminate the provider from the plan. In these instances when a provider is terminated, the plan may not allow assignment of benefits to non-contracted providers, resulting in the patients receiving payment from the plan, not the dentist providing the treatment.  The plan may notify the provider’s patients that he/she is no longer a contracted provider with the plan due to lack of credentialing and the plan may encourage the patient to seek care from another contracted provider.  The plan is within its legal right by taking these actions.

We have witnessed instances where a dentist was terminated based on the information provided on their credentialing paperwork.  This may be tied to a dental board-related action, such as a suspension or revocation of a dental license.  All plans are required to outline the process and procedures, which allow for a dentist to appeal the termination decision of the plan. 

So what are the key takeaways regarding recredentialing? 

  • Expect to have to update your credentialing paperwork every three years for each of your contracted plans. We encourage members to put credentialing expiration dates on their calendars (digital or hard copy).
  • Remind staff to forward all plan correspondence and read your mail carefully.
  • Verify your mailing address with all contracted plans to ensure proper delivery of tax, credentialing and other plan communications.
  • Finally, if you should receive a request for information from a dental plan related to recredentialing, do not be alarmed. Credentialing or recredentialing is a standard process within a licensed dental plan.

For more information regarding the recredentialing process, visit the available resources on cda.org/compass or contact the respective dental plans for which you are a contracted provider.