Dental Insurance Credentialing Process for Dentists

Dental insurance credentialing is the process of verifying the qualifications of a dentist so that payers can add them to the insurance panels. Credentialing for dental practices verifies a dentist’s credentials and completes the necessary contract, allowing a dentist to become part of a PPO network like Delta Dental, Cigna Dental, MetLife Dental, etc., and receive reimbursement as an ‘in-network’ provider from these plans.  

This dental provider enrollment process includes the completion of documentation confirming the dentists’ licensure, education, training, liability insurance coverage, NPI number, and practice information, and completing all contractual obligations with each plan so they can submit claims and be reimbursed for the services provided. 

This blog covers everything dental service providers should know about the dental insurance credentialing process, dental insurance paneling, PPO credentialing for dentists, dental provider enrollment, and how to get credentialed with dental insurance. The blog will also explain the benefits of outsourcing in speeding up dentist enrollment.  

What is Dental Insurance Credentialing? 

Dental insurance credentialing is the process of verifying a dentist’s credentials, background, and professional history prior to allowing them to participate in their networks and treat members as in-network providers. The health insurer reviews the dentist’s educational credentials, state dental licensure, malpractice coverage, employment history, and other data from primary sources to determine whether the provider meets the payer’s quality and safety standards. 

Upon approval of the dental insurance credentialing application, the dentist is then eligible to contract and become ‘paneled’ or ‘participating’ with that plan’s Preferred Provider Organization (PPO) or another network. As a participating provider, the dentists agree to the payer’s plan’s fee schedule, billing requirements, and policies related to obtaining pre-authorization, documenting services provided, and collecting member co-payments.  

Dentist credentialing process is a two-tiered system for providers: 

1. Individual dentist credentialing (Each provider’s licensure, NPI, malpractice coverage, CV, etc.) 

1. Group or facility enrollment (practice tax ID, practice NPI, office location, ownership structure, and billing information) 

The American Dental Association (ADA) has established an ADA Credentialing Services program that allows dentists to store and share basic credentialing information with multiple dental plans, potentially simplifying this process. 

Why Dentists Need Credentialing for PPO Networks 

As a dental service provider, obtaining your credentials and contracted with PPOs (Preferred Provider Organizations) are important to be able to: 

• Get patients who search their insurance providers’ ‘in-network’ dentists through their provider directories. 

• Get paid by your payers on a predictable basis through fee-for-service contracts. 

As a dentist, without PPO credentialing, you can still see patients. However, they will have to pay you directly because you are considered out-of-network’ and: 

• Patients will have to pay for services provided and therefore have less money available to accept and retain treatment. 

• Your claims may be paid at lower allowable fees, and/or the patient may be reimbursed and not your practice. 

Credentialing with dental networks or dental network participation is typically one of the biggest drivers of new patient volume for growing practices and start-ups. Major plans such as Delta Dental, Cigna Dental, MetLife Dental, Aetna Dental, and UnitedHealthcare generally have significant market value in all regions.  

In addition, many buyers also use the number of ‘in-network’ patients as part of their decision-making process regarding whether to purchase a dental practice or employ a dentist. 

Step‑by‑Step Dental Credentialing Process 

Although each of the many different payers will have its individual forms as well as some differences, most dental credentialing processes follow the same general process. 

Strategy, payer selection, and timelines 

Before beginning your dental provider enrollment process, determine:  

• What PPOs you wish to be part of (i.e., Delta Dental, Cigna Dental, MetLife Dental, Aetna Dental, Guardian, Humana).  

• If you enroll in them on an individual basis or through an umbrella or leased network, if they are available (to increase your level of efficient participation).  

Begin dental provider enrollment 90 to 120 days prior to opening your practice, hiring a new associate, or buying a practice, since it may take several months for payers to approve your application. 

Collect documents and information 

Gather all the documentation which payers usually require including: 

• State dental license 

• DEA (if applicable) 

• Malpractice insurance 

•  NPI 

•  CV 

•  W‑9 

• Practice ownership details 

Having a list of required documentation for dental credentialing ready to go will help to greatly reduce the amount of back-and-forth with payers and delays in the credentialing process. 

Set up CAQH profile and payer portals  

Most health plans require a completed CAQH portal, and most dental carriers will either need to access your credentialing information from your CAQH portal, a State Credentialing Portal, or both. Please make sure that:  

• You have completed your CAQH profile to include all relevant information, have verified it to be correct, and attest to the accuracy of the information at least every 120 days.  

• Your NPI (Type 1 individual, Type 2 group) and practice information match the information you provided in your CAQH portal, on your applications, and in your claims data.  

If there are any state-wide credentialing portals, please create them in addition to the above. 

Submit applications to insurance networks 

For each target payer and PPO product: 

•  Fill out the application for credentialing or enrolling in the dental plan (paper or online). 

•  Submit the requested documents. Be sure that all the information provided has matched first and last names, addresses, license numbers, and NPIs. 

• Also, identify your practice location(s), specialties, languages, and type of participation (individual, group, part of a practice).

Primary-source verification and background checks 

This process of primary-source verification is one of the most important aspects of credentialing for dental offices. It allows them to ensure the provider has the necessary education and licensure to provide care and to protect both the patient and them from potential liability for services provided without the proper licensure. After submitting a credential application, the payer’s credentialing department will: 

• Verify the provider’s education and any additional postgraduate training through direct contact with the schools providing it.  

• They will also confirm the active state dental board licenses and DEA registration as well as malpractice insurance and any malpractice or disciplinary action taken. 

• Additionally, a provider’s curriculum vitae will be reviewed to identify any gaps in employment or training for a period of longer than 30 days.

Credentialing committee review 

Most payers will send the application to their credentialing committee or medical/dental director for final review. The committee will consider whether the dentists meet the requirements of the payer’s network (education, training, board actions, etc.) and whether there is a need for another dentist in the ZIP code. 

If the credentialing committee identifies any concerns regarding the qualifications, they may request clarification, documentation, or a letter explaining any discrepancies found during their review of the provider’s application. 

Contracting and fee schedule negotiation 

Once approved by the credentialing committee, the contracting process can begin:   

• The payor will issue participation agreements outlining the terms and conditions, including the fee schedule for participating providers. 

• The provider will review and execute the participation agreement, possibly negotiating fees or electing to participate in selected PPO plans. 

• Once the contract is executed and loaded into the payer system, the dental service provider will be considered in-network and accessible through the payor’s directories.

Effective date, onboarding, and ongoing maintenance 

Once the effective date of the participation agreements has been determined:  

• The provider’s practice will update your practice management software and fee schedules to reflect the network fees for all participating plans. 

• All staff will receive training on the specific plan of rules, pre-authorization procedures, waiting periods, and benefit limitations associated with each PPO Plan. 

• The provider will continue to maintain your credentials over time by renewing their licenses, updating the CAQH profile, and recredentialing every 2 to 3 years, depending upon the payer. 

Required Documents for Dentist Enrollment 

Most payers review the same general set of paperwork to enroll in a dentist. Some of the most common documentation for dental provider enrollment is as follows:  

• An active state dental license for every state in which you provide dental services  

• DEA registration (as needed)  

• National Provider Identifier (NPI) (Type 1 – for the individual dentist, and Type 2 – for the group or practice entity, as appropriate)  

• Certificate for malpractice insurance that includes coverage amounts, insurance carrier and the effective date through expiration date 

• Copy of dental school degree (diploma) and copy of any specialty degrees (e.g. orthodontics, endodontics, etc.) provider may have earned 

• A detailed curriculum vitae (or resume) including all employment history since graduation from dental school, with no breaks in employment  

• Copy of government-issued picture identification, and possibly social security number or proof of income (tax returns, etc.) for identity verification purposes 

• Information regarding provider’s practice, such as business name, DBA, Tax I.D./EIN/W-9, ownership structure, addresses, telephone numbers, and working hours 

• Facility/group licenses, when applicable and any relevant accreditation information  

• References, usually from another dentist or healthcare professional  

In addition to the above, some states and payers also require completion of an updated CAQH profile as part of dentist credentialing into their network. 

Top Dental Insurance Networks in the USA 

The main providers of dental networks vary among states; however, a few major providers dominate dental network participation in each state. Delta Dental, MetLife, Cigna, Aetna, and UnitedHealthcare are the largest and most well-established dental insurance networks in the U.S. and have the highest number of participating dentists, and they tend to have the greatest customer satisfaction as well. 

They all offer very similar types of PPO networks, which are the most popular type of dental network. As such, these networks can give customers the greatest amount of access to both preventive and comprehensive dental health services in the U.S. 

In addition to identifying large national dental plan providers (e.g. Aetna Dental, Cigna Dental, Delta Dental, MetLife Dental), dental practices should also look at regionally strong or niche networks that could be important in specific geographic areas.  

For most practices, targeting a mix of Delta Dental, Cigna Dental, MetLife Dental, and Aetna Dental, along with 2 to 3 regional payers, will likely provide adequate access to the local patient population.  

How Long Does Dental Credentialing Take? 

Typically, the time frame for completing dental credentialing in the U.S. ranges from 90 to 120 days (3 to 4 months), although it can vary depending on the insurance payer and the completeness of the initial application.  

The time to obtain initial credentialing for new providers may be longer than the time required to complete recredentialing for returning providers; recredentialing for returning providers usually requires about 30 to 90 days. 

So, how long does dental credentialing take?  

• 60 to 90 days, for most PPO networks, as long as the provider’s application and all supporting documentation are complete and accurate. 

•  Up to 120 days or longer, where payers have large backlogs, schedule their credentialing committees, and require additional information from the applicant. 

Experts advise that PPO credentialing should begin immediately after signing an associate agreement with a dental practice, or a letter of intent to purchase a dental practice, regardless of whether the start date of the employment or practice ownership is several months in the future. 

Common Dental Credentialing Delays 

Credentialing for dental practices may be delayed or denied by credentialing companies because of common, easily corrected errors.  

Here are some reasons that cause the most common dental credentialing delays:  

• Missing required documents (an outdated malpractice certificate, no CV, missing W-9) 

• Mismatched information (names, NPIs, addresses) between the CAQH profile, applications, licenses, and tax records  

• Unexplained gaps in employment history (more than 30 days)  

• Pending or expired state dental board licensure, DEA registration, or malpractice insurance  

• Disciplinary actions, malpractice claims, etc., that need to be reviewed or supported with additional documentation  

• Lack of regular follow-up with payers to verify they received the application, to track the status of your application, and to provide them with the necessary information 

By implementing a structured credentialing workflow that includes using checklists, establishing timelines, and documenting follow-up communications, dental providers can reduce these potential problems when it comes to credentialing for dental practices. 

How to Get on Multiple PPO Panels Faster 

If a dental practice provider wants to add several PPOs at once, it is best to have an efficient method for carrying it out.  

• Create a standardized package for all documents that are needed for each application. 

• Create a digital file folder containing current license, DEA, malpractice insurance, NPI confirmation, CV, W-9, and other practice-specific information that can be used as templates for each application. 

• Always keep CAQH up to date and make sure to attest to their requirements periodically. 

• Prioritize which dental insurance companies to apply to first by the demand of patients in the local geographic area (e.g. Delta Dental, Cigna Dental, Met Life Dental, Aetna Dental, and other major regional networks). 

•  Complete multiple applications simultaneously rather than one after another, especially when opening a new practice or adding a new dentist or associate to the team. 

• Use a spreadsheet or practice management software to track the status of each application and note the name of the contact person and date for follow-up. 

• Consider using a third-party professional credentialing company to complete the redundant portions of the credentialing process and follow up with the various payors. 

Cost of Dental Insurance Credentialing 

Directly, most payers do not charge much for dental provider enrollment into their network, as they wish to grow their network. The real cost of dental insurance credentialing involves: 

• Administrative time within the in-house to gather the required information, complete the application, and follow up with each individual plan. 

•  Time lost by seeing patients out-of-network or delaying appointments until the credentialing process has been completed may result in lost income. 

Credentialing costs for dentists, on average, for each provider and insurance company in the U.S., are between $200 and $500. Monthly retainer services have costs that can range from $150 to $350, and re-credentialing costs can go approximately $100 for each provider.  These costs can vary depending on the number of payers involved, how complex the credentialing process is, and who handles the credentialing (third-party or in-house). 

When you partner with a third-party credentialing service, you pay: 

• Per-provider fee for each payer to enroll and contract with the plan 

•  Package fees for all providers of a group or a single practice with multiple plans 

These credentialing experts will handle the paperwork, communicate with the payer, and track the status of the application; this should expedite the timeline of when the application will be approved for payment through the plan and help reduce denied claims later. For multi-provider and multi-location offices, third-party credentialing services can be a better option than having dedicated staff handle the credentialing process for dentists. 

Why Outsource Dental Credentialing? 

Outsourcing dental credentialing to an expert company or RCM partner provides numerous advantages. 

• Specialized knowledge of payer requirements: Experts are familiar with each payer’s (Delta Dental, Cigna, Aetna, etc.) form, documentation, and common issues that cause rejection and delay in credentialing approval.  

• Quick credentialing for multiple-network applications: Experienced staff can handle many PPO applications at once, track deadlines, and communicate follow-up information for multiple plans.  

• Administrative load reduction: The providers can focus on case acceptance, scheduling, and patient experience while experts like Credex Healthcare handle credentialing. 

• Compliance with regulations: When providers outsource experts like Credex Healthcare, they receive guaranteed compliance with federal regulations. 

• Reduces administrative workload: Outsourcing can be ideal for busy practices looking to maximize their productivity and patient care while minimizing paperwork. 

FAQs

How long does dental credentialing take? 

Dental credentialing generally takes 60 to 90 days; however, it can extend to 120 days in some cases, and even longer if the documentation is incomplete. Other factors include payer volume, state board requirements, and application completeness. 

What is PPO dental credentialing? 

 The PPO Dental Credentialing process is to verify the qualifications of a dentist and subsequently contract with PPO networks that will allow the dentist to provide treatment to members as an in-network provider.   

Can new dentists join insurance panels? 

 Yes, newly licensed dentists can become an in-network provider for medical insurance companies if the dentist holds an active state license, malpractice coverage, NPI, and proper credentials. Many PPOs recruit newly licensed providers to increase service accessibility.  

What documents are required for dental credentialing? 

Typically, a dentist will be required to submit copies of their state dental license, DEA registration (if applicable), NPI, malpractice insurance certificate, copy of dental school diploma and specialty certificates, CV with complete work history, photo identification, W-9, and practice details including tax ID and addresses.  

How much does dental credentialing cost? 

While insurers typically do not charge high enrollment fees, dental practices may incur costs associated with staff time, lost revenue due to delays, and fees paid to credentialing vendors when outsourcing the application. Many practices have found that outsourcing the credentialing process is cost-effective when credentialing multiple providers or locations. 

Conclusion 

Dental insurance credentialing is an important step for dental practitioners looking to increase patient volume and payment speed, as well as stay in business within highly competitive PPO networks. Handling the credentialing process on your own can be a major time and financial burden, such as delays from 2 months to over 6 months, missing information, and lengthy documentation, making it critical to have professional support to efficiently execute the dentist credentialing process. 

Dental provider enrollment services are available at Credex Healthcare, one of the best credentialing services in the country. The expert team assists in solo practices, clinics, and groups with credentialing, compliance, rapid paneling, and a less stressful workflow.