INSURANCE FEE MAXIMIZATION

Provider Application Request Form

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

[group Member-NO clear_on_hide]

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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[group Member-YES clear_on_hide]

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 Provider Application Request form 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

[group CAQH-YES clear_on_hide]
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 PROVIDER APPLICATION REQUEST TO:*

[group CARRIERS-ID clear_on_hide]
CareingtonConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumanaSolstice[/group]

[group CARRIERS-UT clear_on_hide]
CareingtonConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumanaSolstice[/group]

[group CARRIERS-NV clear_on_hide]
CareingtonConnectionDenteMaxGuardianSun LifeZelisLevelHumanaSolstice[/group]

[group CARRIERS-NM clear_on_hide]
CareingtonConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumanaSolstice[/group]

[group CARRIERS-TX clear_on_hide]
CareingtonConnectionDenteMaxPrincipalLevelHumanaSolstice[/group]

[group CARRIERS-PA clear_on_hide]
CareingtonConnectionGuardianDenteMaxPrincipalSun LifeZelisLevelHumanaSolstice[/group]

[group CARRIERS-WA clear_on_hide]
CareingtonConnectionSolstice[/group]

[group CARRIERS-WY clear_on_hide]
CareingtonSolstice[/group]

Participation Info:

Submit a Provider Application Request form only if the Provider is NOT directly contracted with the selected Carriers. Use the phone numbers below if you need to verify if a Provider is already directly contracted:

[group Careington clear_on_hide]
CAREINGTON
Careington Provider Relations Team 1-800-441-0380 (option 8)[/group]

[group Connection clear_on_hide]
CONNECTION DENTAL(GEHA)
Connection Provider Relations Team 1-800-821-6136[/group]

[group DenteMax clear_on_hide]
DENTEMAX
DenteMax Provider Relations Team 1-800-752-1547[/group]

[group Guardian clear_on_hide]
GUARDIAN
Guardian Provider Relations Team 1-800-890-4774[/group]

[group Principal clear_on_hide]
PRINCIPAL
Principal Provider Relations Team 1-800-638-1959[/group]

[group SunLife clear_on_hide]
SUN LIFE(DHA)
Sun Life Provider Relations Team 1-800-434-2638[/group]

[group Zelis clear_on_hide]
ZELIS
Zelis Provider Relations Team 1-800-878-7896[/group]

[group Level clear_on_hide]
LEVEL
Level Provider Relations Team 1-855-400-5705[/group]

[group Humana clear_on_hide]
HUMANA
Humana Customer Service 1-800-833-2223[/group]

[group Solstice clear_on_hide]
SOLSTICE
Solstice Customer Service 1-877-760-2247[/group]

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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