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Why Do Dental Plans Conduct Credentialing

February 05, 2021 1518

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.

The dental plan credentialing process may include but not be limited to:

  • 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.
  • Graduation from accredited dental school.
  • Specialty training verification.
  • Professional liability insurance.
  • Controlled substance certificate.
  • Application and contract.
  • Malpractice and sanction history.
  • Onsite dental facility assessment.
  • Emergency coverage arrangements verified.
  • Compliance with OSHA/CDC and professional standards are reverified.
  • Recovering provider/chemical dependency verified in compliance with terms of active treatment programs.
  • Physical impairment: Dentists must notify plans in the event they acquire a condition that impairs their ability to practice dentistry.
  • Utilization review: Review reported services, numbers and types of services provided and specialty referrals.

Primary and/or secondary source verified through:

  • State Board of Dental Examiners
  • National Technology Information Services
  • ADA
  • Drug Enforcement Administration
  • National Practitioner Data Bank

If you would like to use the Self-Query service, visit the National Practitioner Data Bank website.

If you should receive a request for information related to credentialing, do not panic. 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. Additional information may be obtained by contacting the professional relations departments at a designated dental plan.