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Adding a Dentist to a Dental Plan as a New Provider

July 27, 2022 494

When adding a new dentist to a dental practice it is required that dental benefit plans be notified of the new provider regardless of the intended plan participation status of the new dentist (in network versus out of network). Failure to do so could result in denied claims, claims improperly processed as out of network when a provider is in network and noncompliance with state law that requires dental plans to maintain an accurate provider directory.

Inform each dental benefit plan that the dentist will be working in the practice. The following best practices are recommended when communicating with the plan:

  • If the associate will be out of network with the plan:
    1. Download and customize the sample letter below to draft a letter to the plan.
    2. Download a W-9 and, following the W-9 example, complete a W-9 for the new dentist.
    3. Attach the above-mentioned documents to the first claim you will submit to the plan for this dentist (must be a paper claim).  
    4. Once the plan has added the dentist to its system of records, you may bill the plan electronically, but do not forget to contact your claims clearinghouse to add this dentist to its system of records.

Important note: Not all dental plans/policies will allow assignment of benefits (AOB) to an out-of-network dentist; this means the patient, not the practice, will receive the payment, and this can happen even if the billing dentist is in network. To avoid collection issues, check with the plan/policy concerning its AOB policy/protocol.

  • If the associate dentist will be in network with a plan:
  1. Request a provider application (see resources at the end of this document for links to plan websites).
    1. When searching the plan’s website for contact information, look for keywords such as “join,” “enroll” and “apply” under the dentist and/or provider section to ensure you get connected with the department that is responsible for contracting.
  2. Thoroughly review the dental plan contract, payment processing guidelines (found in the provider handbook) and the proposed fee schedule to determine the impact on the practice. Also, review Evaluating Dental Benefit Plan Checklist.
    1. As a tripartite member, you have access to dental plan contract analysis services through the American Dental Association. Should you choose to take advantage of this member benefit, contact CDA Practice Support.

Important note: Most dental plans/policies will consider a dentist as out of network while the plan is credentialing/contracting the dentist into its system of records. Most dental plans will not retroactively enroll the dentist. As noted above, some plans will not allow the assignment of benefits to an out-of-network dentist; this means the patient, not the practice, will receive the payment, and this can happen even if the billing dentist is in network. To avoid collection issues, check with the plan/policy to concerning its AOB policy/protocol.

Additional resources:

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