The addition of a new or temporary dentist to a practice brings both excitement and challenges. While focusing on the seamless integration of these professionals into your practice, minimizing disruptions to the care of your patients is crucial. Many dentists understandably have questions about how the new or temporary dentist will contract with the same dental plans the owner dentist participates with. Associates also have questions about participation in dental plans. By understanding the necessary steps and adhering to best practices when informing dental benefit plans and submitting claims on behalf of the new or temporary dentist, you can optimize patient care, maintain strong relationships with dental benefit plans and streamline the administrative aspects of your dental practice.
CDA offers expertise and needed resources to ensure a smooth transition. The following frequently asked questions address key considerations, discuss common challenges and provide practical tips to minimize disruptions while upholding the highest standards of dental care.
Question: What are the steps for credentialing or adding a new dentist to a dental benefit plan?
Answer: That depends on what your intention is when the new dentist begins practicing.
If the intention is to have the new associate dentist bill for patient treatment as an out-of-network dentist, you need to notify the dental plan of the addition and provide them with the new dentist’s full name, license number and individual NPI number (also known as an NPI1).
When adding a new out-of-network associate dentist, practice owners and the new associate should be aware that:
- Patients benefit levels, annual maximums and copayments could be affected when treatment is provided by an out-of-network dentist.
- Some dental plans will not allow assignment of benefits to out-of-network treating dentists; therefore, the reimbursement payment will go directly to the patient.
If the intention is to have the new associate contracted with the dental benefit plan as a participating, fully credentialed dentist, more steps and information are required than if you were simply adding an out-of-network dentist. Contact the dental plan to request a new provider enrollment package and confirm the documentation needed for adding a new contracted provider.
Practice owners and the new associate should be aware that:
- A dental benefit plan provider agreement is a contract between an individual dentist and the dental benefit plan, not between the dental practice and the dental plan. Therefore, dentists who are new to a practice and want to contract with a dental plan will need to sign their own contract with the dental benefit plan to be considered a participating provider.
- The participating provider agreement between the practice owner dentist and dental plan cannot be transferred to or shared with an associate or partner.
Question: What additional documentation and information does a plan need to add a contracted provider?
Answer: Credentialing and contracting a new dentist with dental benefit plans in California involves several key steps:
- Confirm proper licensure and credentials. Ensure that the new dentist possesses all the necessary licenses and credentials required by the dental benefit plans. This includes a valid California dental license, DEA registration, malpractice insurance and any additional certifications mandated by the plans.
- Submit required documentation. Gather and submit the necessary documentation to the dental benefit plans for the credentialing and enrollment process. This typically includes completed enrollment forms, copies of licenses and certifications, proof of malpractice insurance and professional references.
- Facilitate the enrollment process. Work closely with the dental benefit plans to expedite the credentialing and enrollment process. Stay proactive by following up on the status of the application and providing any additional information or clarifications required by the plans. Timely completion of this process ensures a smooth transition for the new dentist.
Question: While a new dentist is in the contracting/credentialing process, can claims submitted for treatment rendered by the new dentist be submitted using the supervising or owner dentist’s license and NPI information?
Answer: No. A claim form is a legal binding document, and the information reported on the claim form needs to include factual and accurate reporting of the treating dentist. Misrepresenting information on the claim form would be considered a fraudulent billing practice.
During the contracting/credentialing process, practice owners and new associate dentists should be aware that:
- Out-of-network dentists can still treat patients during the credentialing process (see above on things to consider when treating patients as an out-of-network dentist).
- Dental plans do not consider a dentist in network until the credentialing process is completed and therefore will not “back date” claim processing to the date the application was submitted.
Question: I am hiring an associate dentist to work part time in my fee-for-service practice, and this dentist also works part time at another dental practice. Do I need to be aware of any dental plan contracting considerations?
Answer: Although dental plan contracts are specific to individual dentists, some contracts contain portability clauses that allow the contract to be shared among locations. Possibly, a dentist has a signed contract at another location and the terms and conditions of that contract would apply at additional practice locations. Be sure to work with the associate and review the contract to verify whether the contract is portable.
Question: What resources does CDA offer to practices that are adding new dentists?
Answer: CDA members can log in to access:
Question: What does it mean to add a dentist to a practice based on locum tenens?
Answer: Under certain circumstances, dental benefit plans will allow a dentist who is not contracted with the dental plan to treat patients, submit claims and be paid as if they were a fully contracted provider as a “locum tenens” for a temporary period. Each dental benefit plan has its own policies for recognizing a locum tenens provider. In the event of a dentist’s death or incapacity, it is extremely important to contact the dental plans and request a locum tenens accommodation as soon as possible to avoid any billing issues or delay of patient care.
Some common scenarios when locum tenens may be utilized in a practice:
- Maternity/paternity leave
- Disability leave (accident)
- Death
In the event of death or disability of a practicing dentist, California state law allows a nonlicensed, legally appointed individual to operate a dental office for a period up to 12 months. The legally appointed person can employ licensed dentists and dental assistants and charge for their professional services.
Question: What do I need to know about utilizing locum tenens as a temporary contracted provider?
Answer: When employing locum tenens, be prepared to:
- Understand locum tenens arrangements. Clearly define the terms of the locum tenens agreement, including the duration of the assignment, responsibilities, compensation and any specific requirements set by the dental benefit plans.
- Know time limits and documentation requirements. Some dental benefit plans in California may have time limits for utilizing locum tenens. California state law only allows locum tenens for 12 months. Familiarize yourself with these limits and ensure compliance. Additionally, understand the documentation requirements for reporting locum tenens services because they may vary between plans.
- Adhere to plan-specific guidelines. Each dental benefit plan has its own guidelines for using locum tenens. Review these guidelines carefully and ensure compliance. Failure to adhere to plan-specific guidelines may result in claim denials or potential penalties.
Question: What locum tenens resources does CDA offer?
Answer: CDA members can log in to access these additional resources when considering locum tenens:
- Unexpected Death of the Dentist
- Prevent Billing Problems and Stress During Leaves of Absence
- Sample Letter to Third Party Payer for Temporary Dentists
Question: Are there additional considerations for claim submissions after adding a new dentist or utilizing locum tenens?
Answer: As is always the case, accurate and timely claim submission is essential for maintaining a seamless workflow. Consider the following points:
- Understand plan-specific coding and billing guidelines. Familiarize yourself with the coding and billing guidelines of each dental benefit plan you participate in. Ensure that the new dentist or locum tenens is also aware of these guidelines to avoid claim denials or delays.
- Document services accurately. Maintain accurate documentation of all services provided by the new dentist or locum tenens. This includes detailed clinical notes, proper coding, and supporting documentation such as X-rays or treatment plans. Accurate documentation helps prevent claim rejections and audits.
- Collaborate with your billing team. Communicate effectively with your billing team or service provider. Inform them about the addition of the new dentist or locum tenens, and ensure they are aware of any changes in the billing process or claim submission requirements. Collaborating with your billing team streamlines the claims process and ensures accurate and timely reimbursement.
- Always ensure claim forms reflect the office’s full fee or usual, customary and reasonable fee and not the contracted rate from the dental plan.
- Any patient discounts must be disclosed on the claim submitted to the patient’s dental plan. Discounts can be noted as a separate line item on the claim form.
In conclusion, properly informing dental benefit plans and submitting accurate claims when adding a new dentist or utilizing locum tenens is essential for minimizing disruption to enrolled patients in California. By following the necessary steps, such as notifying the plans, credentialing and enrolling the new dentist, understanding coding and billing guidelines and collaborating with billing teams, CDA members can navigate these processes effectively and maintain a high level of patient care.