INSURANCE FEE MAXIMIZATION

Change Form Request

IMPORTANT UPDATE - Beginning July 1, 2021, the Dental Cooperative will be exclusively using CAQH as the platform for collecting and verifying Provider credentials as part of the Insurance Fee Maximization process. CAQH is FREE for Providers to create and manage their credentials, reduces repetitive paperwork, and keeps all the information in one place to share with Carriers. If you need help onboarding with CAQH, please contact your local Area Director or the CAQH customer service at 888.599.1771.

Requests can be submitted for an individual Provider only, but you may select multiple Carriers per action. For those using CAQH, please verify the Provider is current and attested before you submit an action below to ensure faster submission. Request forms should not be submitted if the Provider's Dental License, Malpractice Insurance, or DEA Certificate is within 60 days of expiration, due to expiration during processing. If within 60 days, please submit this request after the new Dental License, Malpractice Insurance, or DEA Certificate has been received.

Membership Info:

*required
Requests can only be submitted for current Dental Cooperative Member Providers.
IS THIS PROVIDER A CURRENT MEMBER OF THE DENTAL COOPERATIVE

—Please choose an option—YESNO

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Requests can only be submitted for current Dental Cooperative members. Please contact your local Area Director to add your Provider to the Dental Cooperative before submitting a request. Click here to find your local Area Director:
:: Select Your Area :: Idaho Nevada New Mexico Pennsylvania Texas: West Texas Utah: Central & Southern Utah Utah: Northern Utah Washington Wyoming Area Not Listed

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Practice Info:

PRACTICE NAME*

PRACTICE STATE*

—Please choose an option—IDAHONEVADANEW MEXICOPENNSYLVANIATEXASUTAHWASHINGTONWYOMING

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

COOPERATIVE ACCOUNT# (Optional. Found on your Summary of Benefits.)

Provider Info:

A Change Form request must be submitted individually for each Provider.

FIRST NAME*

MIDDLE NAME

LAST NAME*

SPECIALTY*

—Please choose an option—General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

PROVIDER EMAIL*

DOES THE PROVIDER HAVE A CAQH PROVIDER ID?*

—Please choose an option—YESNO

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CAQH PROVIDER ID

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PROVIDER DENTAL LICENSE#*

DENTAL LICENSE STATE*

—Please choose an option—ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

PROVIDER NPI#*

Carriers Requested:

You may select multiple Carriers. The Practice State in the Practice Info section must be selected to view the corresponding Carriers.

PLEASE SELECT ALL THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR UPGRADE REQUEST TO:*

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CareingtonConnectionDenteMaxPrincipalLevelHumanaSolstice[/group]

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Change Requests:

A Change Form Request must be submitted individually for each Provider, but you may select multiple change requests.

CHANGE REQUESTS:*

TIN change.Provider Name change.Provider Specialty change.Billing address change.Address change.

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New Tax Identification Number (TIN) Info:

Please provide the new TIN data for this Provider.
NEW LEGAL NAME OF ENTITY*

NEW TAX IDENTIFICATION NUMBER (TIN)*

NEW ENTITY TYPE*

—Please choose an option—CooperativeCorporationLimited Liability Company (LLC)PartnershipSole ProprietorshipS CorporationProfessional Corporation (PC)Other

NEW REGISTERED STATE*

—Please choose an option—ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

NEW NAME OF PRIMARY ENTITY OWNER/OFFICER*

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Provider Name Change:

Please provide the new name for the Provider listed above.

FIRST NAME*

MIDDLE NAME

LAST NAME*

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Provider Specialty Change:

NEW PROVIDER SPECIALTY*

—Please choose an option—General DentistDental AnesthetistEndodontistOral Maxillofacial SurgeonOrthodontistPediatric DentistPeriodontistProsthodontist

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Billing Address Change:

Use to update the billing address with the selected Carriers.

NEW BILLING ADDRESS*

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Address Change:

Use to update an existing address. To add a new additional location, click here to use the Add Location Request form.
NUMBER OF LOCATIONS NEEDING ADDRESS CHANGES*

—Please choose an option—12345678910+10

NEW ADDRESS* (enter all address changes here)

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Include any necessary notes, comments, or instructions:

To qualify for Insurance Fee Maximization through the Dental Cooperative, Providers must meet the following criteria:
• Provider must be a current, paying member of the Dental Cooperative in good standing.
• Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
• Provider, must be included in the original Associate Agreement with the Practice. If not included, Provider must sign and submit an Add Member Provider form prior to IFM requests.
• Provider who has terminated their Dental Cooperative membership will have access to fee schedule resources terminated.
• The Dental Cooperative will inform Carriers of membership termination and Carriers will take appropriate action as their individual policies dictate, which may include but not limited to a downgrade of fee schedule, return to previous fee schedule prior to membership or upgrade, or change to a base fee schedule indicated by the Carrier.
• Provider must sign and return Insurance Fee Maximization Provider Agreement prior to any IFM requests.
• The Dental Cooperative acts within the SEC parameters of a Messenger Model. Carriers reserve the right to restrict and deny requests based on their own criteria.

I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed mm/dd/yyyy (required)

Once submitted, we will verify your membership and information. Once verified, you will receive an email with instructions for the next step. Just hold tight until you receive the email.

Please confirm the form submits. You will get a "Success!" message at the bottom of this form if it submits correctly. IMPORTANT: IF YOU DO NOT RECEIVE A CONFIRMATION EMAIL THAT WE RECEIVED YOUR DATA WITHIN 5 BUSINESS DAYS, PLEASE CONTACT YOUR AREA DIRECTOR.

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