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Delta Dental will verify Professional License(s), Certifications and Education experience. Members have peace of mind when choosing a DenteMax dentist because the DenteMax network is made up of the best dentists in the nation. The credentialing form must be filled out and returned to Delta Dental as a part of your participating agreement. Delta Dental of Oregon is a part of Delta Dental Plans Association. A complete copy of this form (“Credentialing Information Form”) for all dentists at the practice A copy of each dentist’s current state license A copy of each dentist’s DEA certificate A copy of the declaration page of each dentist’s malpractice insurance A copy of the diploma from an accredited post graduate training identifying the specialty for each specialist as applicable Specialty only: If trained outside the U.S. or Canada, alternate pathways credentialing … Rules for participating dentists Register a Super User for your office today! 922 0 obj <> endobj For dentists who are newly applying to join our networks or participating dentists who are adding an office location, please contact Provider Services at 1-800-537-1715 extension 1100. To accomplish this, we credential new Delta Dental dentists and conduct re-credentialing of contracted dentists at least once every three years.*. For other Delta Dental Plans Association member companies, visit the Delta Dental Plans Association website. 4. > The dentist may request the initial application be revisited if corrections are made within 180 days of the re-credentialing decision, or may re-apply if the 180 day time requirement has lapsed. Complete, sign, and date the forms. Return to top DCPG re-credentials our providers on a rolling three-year basis from the date when each provider was approved for network participation. Optional Treatment Consent Form Use this form if your patient elects to have optional treatment completed. 1112 0 obj <>stream h�쐭 Q�Ͻ�U_A��.��Q�}�l1 ��i6A� �`�Y|a���3�^��U�-g�af���@mh���>� #��Ʉ���#��y�L�6�G��7r�zL���=>�ϝY[%V5��$���4~η��~���9df��.�'�z�͹a�mX���ʘާ���T)���i#é\AW���w��R>]h�Ҍ�P��O`�y 0 �xT4 This new capability, developed for us with DentalXChange, simplifies recredentialing for … Delta Dental focuses on getting patients into your office as an essential part of achieving and maintaining good oral health. endstream endobj startxref h޴TWLQ=3;;;+��#�Xp�U�PD쨳V�b/��!�D�����l���"p���qU���ʊ��?��û��ˇ7���ɹ�s�� �� 0.2~�L�R5|>�+*�VLX��[+#�ŭY�zU�ژhsC��m;޼5�W�-/;g;=��t���KE��W�ޮ}x��ɋ��vU?xv��K��;wU����x��w�_96/Y�x����s���M��O?h9��nݗ���Z�u�ء�'d�?�{�HN��k�#&������I����Vn u���>�4áG)��Ae��t�����2=,|gD*��/E�hb�=Ф You can download this form, insert the necessary information, and print it or you can print it and fill in the applicable information. Delta Dental maintains a file of your credentialing information. Northeast Delta Dental Credentialing and Re-Credentialing Application Instructions: 1. Delta Dental has partnered with DentalXChange to bring you online recredentialing Your entire recredentialing process with Delta Dental of New Jersey & Connecticut will now take place online. Delta Dental offers dentists the flexibility of participating with one or both of our networks: Delta Dental Premier® Delta Dental Premier® is a standard fee-for-service program. Practice Information Update Form: Use this form to notify Delta Dental of New Mexico about changes to practice information, such as the street address or office hours. Confidential Re-Credentialing Information Form This form must be completed by the contracting dentist. Required fields will be outlined in red and must be completed in order to submit your application. Forms for Our Providers and Their Office Staff Find the helpful forms and materials to assist you with processing Northeast Delta Dental claims and much more. Treating dentists must maintain eligibility throughout the … We will verify your credentials every three years — please use the Oregon recredentialing form after your first filing. Please note: If you have recently registered on the Delta Dental of Michigan website (Consumer Toolkit), registration may take a few minutes to sync for access to the Delta Dental National Portal and Mobile app. Fax the completed forms to (888) 404-8725 or send to address below or email to: ProviderRequests@deltadentalmi.com. Let us know in writing when you change your address; sell, buy, open or close an office; add a dentist, change your name or specialty … Delta Dental maintains a file of your credentialing information. Delta Dental will verify your credentials every three years — please use the recredentialing form after your first filing. Provider Records Delta Dental Plan . Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. Re-credentialing — Current Dentists. We recommend that you retain a copy of the credentialing form for your records and make a note of the date mailed and the address to which you mailed it. Dentist Name (Please Print): Dentist’s Signature: Date (mm/dd/yyyy): Form No. I hereby certify that the information requested by Delta Dental of Washington and provided herein is truthful, correct and complete in all respects. %%EOF Agreement, W-9, Disclosure of Ownership, and state required forms along with your full name and CAQH ID using the chart Option 3: Begin an online application with CAQH. Appeal Form - Information on how to appeal your claim ; Delta Dental Premier Network Forms - Professional Application & Credentialing form, Delta Dental Premier Dentist's Agreement, Ownership & Control Form and W-9 Box 30416 Lansing, MI 48909-7916 * *PROVIDERS CANNOT BEGIN TO TREAT ENROLLEES UNTIL A WELCOME LETTER FROM DELTA DENTAL IS RECEIVED Delta Dental Provider Credentialing Process We appreciate your assistance and cooperation with this important process. 3. Dentist Forms . All dental benefit carriers are required to use and accept the CAQH form for credentialing Ohio dentists. Mail this form to Delta Dental Mail: PO Box 40384 Portland Oregon, 97240-0384 Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon. Use this form to refer your patient to a specialist. Delta Dental has partnered with DentalXChange to bring you online recredentialing Your entire recredentialing process with Delta Dental of New Jersey & Connecticut will now take place online. Each dentist participating with Northeast Delta Dental needs to complete this application in its entirety at least once every three (3) years. * When you receive the Confidential Credential Information Form from us, please complete and return it by the date indicated in the cover letter. The Dental Care Cost Estimator provides an estimate and does not guarantee the exact fees for dental procedures, what services your dental benefits plan will cover or your out-of-pocket costs. ©Arizona Dental Insurance Service, Inc. dba Delta Dental of Arizona. If you already participate, but want to join another network, or have questions about your participation status, please contact Delta Dental of Colorado’s network management team at 303-889-8677. 1033 0 obj <>/Filter/FlateDecode/ID[<7BB7C3DCE6BE6C4F95A494BABE3D1EE7>]/Index[922 191]/Info 921 0 R/Length 215/Prev 411140/Root 923 0 R/Size 1113/Type/XRef/W[1 3 1]>>stream Delta Dental PPO and Delta Dental Premier network dentists submit claim forms automatically on behalf of Delta Dental patients. It is for precisely this reason that DenteMax requires credentialing before a dentist is accepted into the network, and then requires re … 0 Our mission is to improve lives by promoting optimal oral health. Numerous contractual and regulatory requirements obligate us to ascertain that contracted Delta Dental Premier and PPO dentists are legally qualified to practice. Through our national network of Delta Dental companies, we offer dental coverage in … ׁF���)���>$@�.���h�5�� Uu7�r�{�����7���Ty���ӗ�nU?xx�v핫�ŗ�.��.�+9������쵋�g���^��@�ޓ�e��NMK���H��u������oM��7lIؼg�m�1k�V���\�&n]��ys�̞5s��iSæL?a�А�cƎ5B1�. *Our credentialing and re-credentialing processes include gathering information from several sources, including professional associations, regulatory agencies and educational institutions, as well as from the prospective or contracted dentist, to assess the dentist’s legal qualifications to practice dentistry. There’s no hassle in working through claims, saving you time and frustration. This new capability, developed for us with DentalXChange, simplifies recredentialing for … Title: Microsoft Word - Recred App May 2009.doc Author: redwards Created Date: 5/18/2009 1:01:38 PM Delta Dental of Minnesota has moved to an electronic credentialing system. Treating dentists must maintain eligibility throughout the … Re-credentialing is required by state and federal regulators and Delta Dental, and it’s important to your patients, too. Your responses on this form will be used to determnei whether you meet the eligibility criteria for participation in thenetwork. When a different address is used, your clearinghouse may not recognize it as a valid address for … Your responses on this form will be used to determine whether you meet the eligibility criteria for participation in the network. CONFIDENTIAL CREDENTIALING INFORMATION FORM This form must be completed by thecontracting dentist. The Oregon credentialing form must be filled out and returned to us as a part of your participating agreement. Nationwide, Delta Dental covers more than 80 million people actively seeking treatment from participating dentists. Register %PDF-1.6 %���� Dental plans in Alaska provided by Delta Dental of Alaska 60152777 (1/20) Section 1: Practitioner and practice information 2. This form is not needed for orthodontic referrals. P.O. Website Registration. �PB֝�����F4"�(�'-��� ���@x�9�|8�\��JD�"bx2�A����eNQ��%j��PZ��C���)-(��]�X�B&>����JGE�>q�\�(���d� Your social security number (required to obtain necessary reports), Your billing and/or rendering NPI, as appropriate (if you have not previously registered it with Delta Dental), Copies of your certificates of coverage for professional liability insurance, For specialists, a certificate of specialty or Board eligibility, Written explanations of your form responses, if applicable. This website is the home of Delta Dental of California; Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; Delta Dental of West Virginia, Inc. and their affiliated companies. FAQs About Participation with Delta Dental Premier Delta Dental of Washington is a part of Delta Dental Plans Association. We will keep the information you provide secure and confidential. ... the credentialing and recredentialing application. Update Your Information. Check eligibility, benefits and claims status. ��s+P�d!+�v�x�4ƣd�5�D}��P�#e�/��DI'p�N�?S�Ȟ�,����A��d��(��}\>BЅɐ���2�A��L>���风1d,F�� #��$�E��&���9�`Ta>��զ� CHECKLIST The following documents are required for credentialing as a Delta Dental Participating Provider: Completed Participating Dentist Credentialing Agreement that is signed and dated. How to become a … Re-credentialing occurs every three years Numerous contractual and regulatory requirements obligate us to conduct the re-credentialing process and to terminate the Delta Dental contracts of dentists who do not complete the process. Don't take chances with your network status -- be sure to return th Please call 1-800-448-3815 and select credentialing from the list of options. RC102219 A copy of current valid anesthesia license (if applicable). Alternatively you may email mncredentials@mydeltadental.com to begin the electronic process. Dental Recredentialing Application Ready to submit? DeltaCare Facility Audit Form Use this form when you're a new DeltaCare provider or have moved to a new location. Address for all claims (paper and electronic) for Delta Dental of Michigan, Ohio, Indiana, and North Carolina: Delta Dental PO Box 9085 Farmington Hills, MI 48333-9085. To accomplish this, we credential new Delta Dental dentists and conduct re-credentialing of contracted dentists at least once every three years. Estimates should not be construed as financial or medical advice. 11. When you receive the Confidential Credential Information Form from us, please complete and return it by the date indicated in the cover letter. Delta Dental will send a packet of information, including this form, to dentists who are setting up an initial participation agreement or who are due for recredentialing. © Delta Dental. This claim form is for Delta Dental PPO, Delta Dental Premier and non-network claims. In addition to providing answers to the questions, we need the following information as well: We request only essential information that we must have to verify your qualifications through the required agencies and databanks. Health insurance carriers are required by all states to re-credential their participating providers. With Delta Dental, we keep you smiling. Dental plans provided by Oregon Dental Service (ODS), dba Delta Dental Plan of Oregon and Delta Dental of Alaska. When you receive your re-credentialing letter and form from us, be sure to: Mark the due date indicated in the letter on your calendar and “To Do” list. Participating Provider Manual; Provider Association Form: Active Delta Dental Participating Providers can use this form to add a new office location without needing to fill out the full Provider Credentialing Profile. If the problem persists, please contact Customer Service using the Contact Us tool. Re-Credentialing Initial Credentialing 1. Northeast Delta Dental for the purpose of evaluating my application, credentials, and qualifications and for the purpose of updating any information requested in this application prior to my next re-credentialing. 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