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Insurance Plan Credentialing

September 29, 2021 1124

Dental credentialing is the first step in the process of a dentist entering into a contract with a dental benefit/insurance carrier. Credentialing or recredentialing is a standard process within a licensed dental plan. The intention of the credentialing process is to ensure that enrollees who select a participating dentist can be confident that the dentist has met minimum, uniform requirements. Dental plans conduct credentialing, which is the collection and verification of an applicant’s professional qualifications, such as relevant training, licensure, certification and/or registration, to practice in a health care field and academic background as well as an assessment of whether the practitioner meets certain criteria relating to professional competence and conduct. Licensed health care service plans are required to monitor the qualifications of their participating providers and follow National Committee on Quality Assurance (NCQA) standards.

Dental credentialing is done on an individual basis and must be completed for each plan in which the provider chooses to be contracted (in network). As an associate, you must credential with each plan in which you and the practice owner agree for you to become an in-network provider. Each provider has a choice to be in or out of network with a dental benefit plan. The dental insurance contract will be executed between you as the provider and the dental insurance plan. It is important to understand in advance of your employment acceptance the plans in which the owner is in network and whether the owner wants you to be in network as well. If you are paid by the employer as a percentage of collections or production, the dental insurance plan contracts you sign will impact the fees you will be paid, which will impact your compensation.

Standard documents requested during credentialing processing are:

  • State license: Renewals of state licenses are periodically verified by plans according to the cycle of license renewal established by each licensing entity.
  • Drug Enforcement Agency (DEA) or controlled substance certificate: A copy of a new and/or updated certificate is required at the time the participating dentist is recredentialed.
  • Diploma from accredited dental school.
  • Specialty training verification.
  • Professional liability insurance.
  • Application or contract.

Additional documents that can be requested at credentialing or recredentialing are:

  • On-site dental facility assessment.
  • Emergency coverage arrangements verified.
  • Compliance with OSHA/CDC and professional standards are reverified.
  • Malpractice and sanction history.
  • Utilization review: Review of reported services, numbers and types of services provided.
  • Physical impairment: Dentists must notify plans in the event they acquire a condition that impairs their ability to practice dentistry.

Primary and/or secondary source verified through:

In order to expedite the credentialing process, it is best to have copies of these standard documents ready to provide to an employer as soon as an employment contract is signed.