dentegra insurance application

7/27/2019 Dentegra Insurance Application

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CONTENTS

Dentegra Participating Provider Agreement

Taxpayer Identication Number (TIN) Request Form

Condential Credentialing Information Form

Ofce Information for Online Dentist Directory

Complete and sign the agreement on page 7 and all

forms on pages 8-14. Please make a copy of this booklet

for your records and return the entire original booklet to:

Dentegra Insurance Company

ATTN: Contracting and Administration

100 First Street M/S 5J

San Francisco, CA 94105


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DENTEGRA PARTICIPATING PROVIDER AGREEMENT

This agreement (Agreement) is entered into by and between the undersigned dentist, dental partnership, professiona

dental corporation, dental clinic, or dental care provider (Provider) and Dentegra Insurance Company 1 (hereinafter

Dentegra).

This Agreement shall become effective upon Dentegras initial written notice to Provider as set forth in Section I.2, below.

RECITALS

A. Dentegra issues or will issue various contracts to purchasers of dental care insurance or dental network access

programs (Programs) for designated eligible enrollees (Enrollees). Such Programs arrange for certain dental services

(Program Services) to be performed by dental care providers contracted with Dentegra (Participating Providers)

Program Services include dental care services for which the Program is obligated to pay pursuant to an Enrollees

Program contract, or for which the Program would be obligated to pay pursuant to an enrollees Program contract bu

for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual o

lifetime maximums, frequency limitations, or alternative benet payments.

B. Provider desires to be a Participating Provider in such Programs and therefore agrees to the terms and conditions o

participation as stated in this Agreement.

I. SELECTION AND PARTICIPATION

1.0 Eligibility. To participate in the Programs, Provider must submit all required credentialing documents for each and

every licensed dentist (including Provider) whom Provider intends to render dental services to Enrollees on Providers

behalf (Rendering Professionals) and receive approval from Dentegra for each such Rendering Professional who

meets Program credentialing criteria as determined by Dentegra. Such criteria include, but are not limited to:

(a) Licensure. Provider warrants and represents that each Rendering Professional is now and shall continue to be

the holder of a currently valid, unrestricted license to practice dentistry issued by an appropriate state agency,

and that no Rendering Professionals license has been suspended, revoked or terminated or subject to terms

of probation or other restriction within the past ve (5) years. Provider also warrants and represents that each

Rendering Professional has not been excluded from participating in any government-sponsored programs.

(b) Facilities and Equipment. With respect to each and every facility where Enrollees shall receive treatment, Provide

shall ensure that such facilities are of adequate capacity and are clean, safe and readily accessible to Enrollees

All equipment used in such facilities shall be licensed and regularly checked as required by state and federal law

to ensure that it meets health and safety standards, is environmentally safe and technically accurate.

(c) Insurance. Provider shall secure and maintain from insurance companies acceptable to Dentegra and

approved to conduct business in the state where Provider is located, professional liability insurance and such

other insurance as required by reasonably sound business judgment to protect Provider and each Rendering

Professional (Insureds) and the Insureds partners, shareholders, directors, ofcers, members, employees and

agents against losses and liabilities attributable to their acts or omissions in the performance of this Agreement

Such insurance shall have limits of coverage considered reasonably adequate by Dentegra for the risk insured

against. Provider shall give Dentegra written notice within ten (10) days of cancellation or other termination ofsuch policy.

1.1 Selection. Dentegra may, at its sole discretion, select Provider for participation, based upon Dentegras determination

of Providers eligibility and need for Providers services. Dentegra may also, at its sole discretion, select or deselec

individual Rendering Professionals based upon Dentegras quality management program, as described in Section V

of this Agreement.

1.2 Notication of Selection. Dentegra shall notify Provider in writing of Providers selection as a Participating Provider and

when any Rendering Professional has been approved to treat Enrollees.


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II. REQUIRED ADMINISTRATIVE PRACTICES, DISCLOSURES AND LEGAL COMPLIANCE

2.0 Dental Services. Provider agrees to provide Program Services for any Dentegra Program to eligible Enrollees in

accordance with the terms, benets, limitations and/or exclusions for the eligible Enrollees Program.

2.1 Availability. Dental services are to be available during Providers regular business hours. Emergency Services shall be

available twenty-four (24) hours per day, seven (7) days per week, including vacations and holidays. Provider may no

impose any limitations on the acceptance or treatment of Enrollees not imposed on other patients.

2.2 Locations. Provider shall submit information as required by Dentegra to accurately maintain its records for eachofce where Enrollees will receive dental services from Provider. This includes, but is not limited to the name and Tax

Identication Number, as registered with the U.S. Internal Revenue Service to be used by Dentegra to issue paymen

for services, any business entity name, new or deleted ofce locations, the attributes associated with each ofce (e.g

hours open, languages spoken), etc. Ofce locations will not be activated until at least one dentist at the location, in

the appropriate specialty, is approved by Dentegra as a Rendering Professional per Section 1.0.

2.3 Eligibility Verication. Provider shall verify an Enrollees eligibility to receive Program Services at or before each vis

in accordance with procedures established by Dentegra. Failure to verify eligibility may result in forfeiture of payment

including applicable Enrollee payments.

2.4 Enrollee Grievance Procedures. Provider agrees to cooperate with Dentegra in identifying, investigating and resolvin

Enrollee grievances pursuant to applicable review procedures as described on our website or in written correspondence

connected with specic grievances, and in accordance with state and federal regulatory guidelines as applicable

Provider agrees to comply with all nal complaint and grievance determinations by Dentegra.

2.5 Standard of Care. This Agreement shall not affect the provider/patient relationship between Provider and Enrollees

Provider shall render all services in accordance with generally accepted dental practice and standards prevailing in

the professional community at the time of treatment. It is Providers responsibility to disclose various treatment options

and the estimated costs associated with each option, regardless of whether or not they are Program Services unde

the Enrollees Program, and to secure the written consent of the Enrollee.

2.6 Rendering Professionals. Provider shall timely identify Rendering Professionals to Dentegra throughout the term o

this Agreement. Provider shall not permit any Rendering Professional to provide services to eligible Enrollees on

Providers behalf unless such Rendering Professional has been approved by Dentegra as a Participating Provider

Provider shall ensure that each Rendering Professional complies with the terms and conditions of this Agreement.

2.7 Required Disclosures. Provider agrees to notify Dentegra immediately in writing upon the occurrence or discovery o

any of the following:(a) The license to practice dentistry of Provider or any Rendering Professional expires and/or is not renewed, i

suspended, revoked, terminated or subject to terms of probation or other restriction;

(b) Provider or any Rendering Professional becomes the subject of any disciplinary proceeding or action before

state or federal agency;

(c) Provider or any Rendering Professional ceases to participate, is suspended or loses eligibility to participate i

any state or federally sponsored dental program;

(d) Provider or any Rendering Professional is accused or convicted of fraud or a felony;

(e) The cancellation, termination or expiration of insurance coverage required under this Agreement;

(f) A malpractice action is instituted, settled or decided against Provider or any Rendering Professional;

(g) Provider les a voluntary petition or an involuntary petition is led against Provider seeking bankruptcy

reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or an

other laws governing insolvency or debtor relief;

(h) An act of nature or any event beyond Providers reasonable control occurs which substantially interrupts o

interferes with all or a portion of Providers practice or which has a material adverse effect on Providers ability to

perform hereunder;

(i) A material change in the membership, ownership, and/or ofcers of Providers dental practice/corporation; or

(j) Any other situation arises which could reasonably be expected to affect Providers ability to carry out th

obligations of this Agreement.



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To the extent reasonably appropriate and subject to any applicable state or federal fair hearing requirements, Provider

shall immediately restrict, suspend or terminate a Rendering Professional from providing services to Enrollees upon the

occurrence of any of the events referenced in Section 2.7. If Provider fails to act as required by this paragraph with respect to

a Rendering Professional, Dentegra shall have the right to immediately prohibit the Rendering Professional from continuing

to provide services to Enrollees.

2.8 Legal Compliance. Provider and Rendering Professionals shall:

(a) Treat Enrollees with the same quality and provide access to care consistent with the balance of Providers

practice and not differentiate or discriminate against any Enrollee on the basis of source of payment; and

(b) Not unlawfully differentiate or discriminate against an Enrollee, employee or applicant for employment on the

basis of race, religion, color, national origin, ancestry, place of residence, physical handicap, medical condition

marital status, sexual orientation, age or sex; and

(c) Comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age

Discrimination Act of 1975, the Americans with Disabilities Act, Public Law 103-227 (US. Pro-Children Act of 1994

[20 USC 6081, et. seq.] and Section 1352 of Title 31), United States Code regarding prohibitions against using

federal funds for lobbying; and

(d) Not employ or contract with, directly or indirectly, entities or individuals excluded from participation in Medicare o

Medicaid under sections 1128 or 1128A of the Social Security Act, for the provision of dental services, utilization

review, medical social work or administrative services; and

(e) Not condition treatment or otherwise discriminate on the basis of whether an Enrollee has executed an advance

directive (as advance directive is dened under federal law).

(f) Comply with all applicable federal, state and local laws and regulations relating to administrative simplication

security, and privacy of individually identiable Enrollee information, including but not limited to the federal Health

Insurance Portability and Accountability Act of 1996 (HIPAA).

2.9 Condentiality of Dentegra Information. Provider and Rendering Professionals shall keep condential and take

necessary precautions to prevent the unauthorized disclosure of Dentegras condential and proprietary information

including without limitation its nancial arrangements with Participating Providers and any other information compiled

or created by Dentegra and identied in writing as condential and proprietary. Upon the termination or expiration

of this Agreement, Provider shall return to Dentegra all condential and proprietary information in the possession of

Provider or any Rendering Professional.

III. PROGRAM ADMINISTRATION

3.0 Administration. Dentegra shall perform or contract for those services necessary to the administration of the Programs.

3.1 Eligibility/Authorizations. Dentegra shall conrm the Program eligibility of Enrollees and the benets under the

Enrollees Program through the Dentegra website and automated telephone services.

3.2 Processing Policies and Procedures. Dentegra shall make information describing Dentegras general policies and

procedures and the policies and procedures of the Programs available to Provider and Rendering Professionals through its

website and upon request

3.3 Benet Determinations. Dentegra shall be solely responsible for interpreting the terms of and making nal benet

determinations under each Program with respect to Program Services and/or Enrollee payments.

3.4 Rationale For Rejection of Claim. Dentegra shall, where required, disclose the rationale used in rejecting or denying

a claim submitted by Provider. Dentegra shall pay Providers claims under the Programs in accordance withapplicable state or federal prompt payment laws.

IV. COMPENSATION

4.0 Fees. Dentegra shall establish the fees payable to Provider as set forth in the Condential Schedule of Contracted

Fees, applicable to the Rendering Professionals specialty and region, which is in effect at the time Program Service is

provided to an Enrollee. Dentegra shall pay Provider the portion of such fees that are not payable by the Enrollee based

on the Enrollees Program. Such Condential Schedule(s) of Contracted Fees are incorporated into this Agreement by

this reference at the time they are issued to Provider in accordance with Section 8.0 of this Agreement. Any Condentia

Schedule of Contracted Fees should not be disclosed by the Provider to a third party without the express permission o

Dentegra. Provider agrees to accept no more than these fees as the total fee chargeable for Program Services.



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4.1 Claim Submission Requirements. For those Programs where Dentegra is responsible for paying any portion of Providers

fees, Provider agrees to submit claims and provide Dentegra with claim data according to the policies and procedures

set forth on the Dentegra website and consistent with requests in any written communications between Dentegra and

the Provider. Provider further agrees to follow any applicable state and federal laws with respect to claim submission

requirements or data elements associated with such transactions. This includes, but is not limited to, the guidelines found

in the Health Insurance Portability and Accountability Act (HIPAA). Provider also agrees, upon request, to provide any

other information that will enable Dentegra to meet federal, state and local reporting requirements.

Provider further agrees to:(a) Submit complete and accurate claims for all services provided to eligible Enrollees, whether Program Services or not;

(b) Include the fee regularly charged by Provider for such services;

(c) Use claim forms or formats acceptable to Dentegra;

(d) Submit claims within twelve (12) months after the date services were performed. Should any amount be denied

by Dentegra for late submission, Provider agrees not to charge the Enrollee any balance that would have been

paid by Dentegra if the claim had been submitted on a timely basis.

4.2 Enrollee Payments. Provider shall bill and collect any deductible, copayment and/or coinsurance from the Enrollee in the

amounts determined by Dentegra to be applicable based on the Enrollees Program. Provider shall also bill and collect no

more than the amounts set forth in the Condential Schedule of Contracted Fees for those Enrollees in network access

programs (please refer to paragraph 4.5 for obligations associated with optional treatment and non-Program dental services).

Provider shall not waive, reduce or rebate any amount determined by Dentegra to be payable by an Enrollee.

4.3 Prohibition Against Certain Billings and CollectionsProvider agrees to accept fees described in Paragraph 4.0 plus the

Enrollee payments, pursuant to Paragraph 4.2, as payment in full for Program Services and not to seek any surcharge

or other additional payment, regardless of whether or not payment is received from Dentegra. Whenever Dentegra

receives notice of a surcharge, it shall take appropriate action. Neither Enrollees nor a Programs sponsoring entity

shall be liable to Provider or any Rendering Professional for any sums owed to Provider by Dentegra. The foregoing

shall not preclude Provider from billing and collecting authorized Enrollee payments pursuant to Paragraph 4.2 or third

party collections in accordance with Paragraph 4.4.

4.4 Third Party Payments. Provider shall cooperate with Dentegra in the proper collection of third party payments including

coordination with other coverage, workers compensation, third party liens and other third party liability. Provider

agrees to disclose any other insurance for which the Enrollee is also eligible on any claims submitted to Dentegra.

Furthermore, if Dentegra is secondary, the Provider agrees to provide the explanation of benets provided by thecarrier that adjudicated the claim as the primary payor.

4.5 Optional Treatment and Non-Program Dental Services.Unless a nancial responsibility/optional treatment form has

been executed between Provider and the Enrollee or the Enrollees legal representative, Provider shall not bill or

collect from an Enrollee any charges in connection with a dental service even though that service is: (i) not a Program

Service; (ii) not listed on the Condential Schedule of Contracted Fees; or (iii) an optional form of treatment that is

more expensive treatment than is customarily provided. Total reimbursement for any Program service performed shal

not exceed (i) the amount listed on the Condential Schedule of Contracted Fees; or (ii) for a service not listed on the

Condential Schedule of Contracted Fees, the fee that is accepted by Dentegra.

4.6 Deductions and Refunds. Dentegra shall have the right to deduct and set off from amounts due to Provider any amounts

owed by Provider to Dentegra or to Enrollees as a result of Providers failure to fulll any business or patient obligation

under this Agreement or Dentegras policies and procedures. Enrollees shall not be liable to Provider or any Rendering

Professional for any such amount deducted or set off by Dentegra (or refunded by Provider) and Provider agrees not toattempt to collect any set off amount from Enrollees or maintain any action at law against Enrollees to collect such amounts

4.7 Non-Reimbursable Service Claims Submission. The submission of a claim for items or services which have not been

provided as claimed is not reimbursable under any Program and is subject to applicable provisions of state and federa

criminal laws.

V. QUALITY AND UTILIZATION REVIEW

5.0 Dentegras Responsibilities. Dentegra may be required by law to conduct quality and utilization review activities that

identify, evaluate and remedy problems relating to access, continuity and quality of care, utilization and the cost

of services. Dentegra shall maintain standards, policies and procedures for credentialing and recredentialing, and

quality and utilization review of Participating Providers, Rendering Professionals, other health care professionals, and

facilities providing dental services to Enrollees.



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As part of its review activities, Dentegra may also use or disclose Providers Tax Identication Number (TIN), Nationa

Provider Identier (NPI) or other attributes to conduct analysis of accessibility, continuity and quality of care or to

perform other dental benet administration activities.

5.1 Providers Responsibilities. Provider and Rendering Professionals shall cooperate and comply with Dentegra, and

designated representatives of organizations engaged by Dentegra, in connection with its quality and utilization review

activities, including but not limited to credentialing and recredentialing, patient record reviews, and facility audits.

5.2 Language Assistance Capabilities. Provider shall contact Dentegra if an Enrollee requests or evidently requires

interpretation services in any language, which services will immediately be arranged by Dentegra at no cost to theEnrollee or the Provider.

VI. RECORDS AND AVAILABILITY FOR INSPECTION

6.0 Dental Records. Provider shall ensure that an accurate and complete patient (treatment and nancial) record for each

Enrollee is established and maintained in Providers facility. At a minimum, such records shall include personal and

health information about the Enrollee, a description of all services rendered to the Enrollee, and charges made and

payments received therefore, as dictated by generally accepted dental practice and standards.

6.1 Access to Dental Records. Subject to compliance with applicable federal and state laws and professional standards

regarding the condentiality of patient records, Provider shall assist Dentegra in achieving continuity of care fo

Enrollees through the maximum sharing of patient records for services rendered to Enrollees. Providers obligations

under this Paragraph shall include, without limitation:

(a) Providing Dentegra with copies of Enrollee patient records that are in the custody of Provider or any Rendering

Professional;

(b) Allowing Dentegra authorized personnel, its designated representatives, accreditation and review organizations

and government agencies access to such records on Providers premises during regular business hours;

(c) Upon reasonable request, providing copies of an Enrollees patient records to any other Participating Provide

treating such Enrollee.

6.2 Inspection, Audit and Maintenance. Provider and each Rendering Professional shall maintain the condentiality of al

Enrollee identiable information, patient records and treatment in accordance with state and federal law. Provider and

each Rendering Professional shall maintain such records and provide such information to Dentegra, the United States

Department of Health and Human Services, or any other appropriate governmental ofcial having jurisdiction as may

be necessary for compliance by Dentegra with state and federal law and the rules and regulations duly promulgated

thereunder, for a period of at least ten (10) years. All facilities, ofces, records, books and papers of Provider and eachRendering Professional pertaining to Enrollees shall be open to inspection by Dentegra, its designated representatives

accreditation and review organizations, and state and federal authorities having jurisdiction over the Program during

normal business hours. Provider and each Rendering Professional shall comply with any requirements or directives

issued by Dentegra, accreditation and review organizations and government agencies as a result of such evaluation

inspection or audit of Provider or a Rendering Professional. The provisions of this paragraph shall survive termination

of this Agreement for the period of time required by state and federal law.

VII. TERM AND TERMINATION

7.0 Term. When executed by both parties, this Agreement shall commence upon the Providers selection date as notied

by Dentegra, pursuant to Paragraph 1.2 of this Agreement, and shall continue in effect until terminated in accordance

with the terms of this Agreement.

7.1 Termination. Either Provider or Dentegra may terminate this Agreement on ninety (90) days written notice. Dentegramay immediately terminate this Agreement upon the occurrence of any of the events set forth in Paragraph 2.7 (a

through (e) (Required Disclosures) subject to any applicable limitations of state or federal law. If this Agreement

is terminated by Dentegra, Provider may not seek to become a Participating Provider until Provider demonstrates

to Dentegras satisfaction that the issues which resulted in the termination of the Agreement have been resolved

Furthermore, unless otherwise stated by Dentegra at the time of termination of the Agreement, Provider may no

reapply for participation for a period of at least twelve months following the termination of this Agreement. Dentegra wil

provide a terminated Participating Provider an opportunity to appeal such termination, as required by applicable state

or federal law or by Dentegra policies and procedures. Any such appeal process shall replace the dispute resolution

procedures described in Section VIII of this Agreement.



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7.2 Continuing Obligations Upon Termination. In the event of notice of termination of this Agreement or a Program, Provide

shall continue to schedule and honor existing appointments of Enrollees until the effective date of termination. As of the

effective date of termination of this Agreement or a Program, the provisions of this Agreement shall be considered of no

further force or effect whatsoever and each of the parties shall be relieved and discharged here from, except that:

(a) Termination shall not affect any rights or obligations that have previously accrued or shall thereafter arise with

respect to any occurrence prior to the effective date of termination and any such rights and obligations shall

continue to be governed by the terms of this Agreement;

(b) Unless Dentegra makes other reasonable and medically appropriate provision for the performance of services,Provider shall complete all dental services begun (but not completed) prior to termination.

(c) Provider agrees to specically notify all Enrollees that the Provider is no longer contracted to render services as

a Participating Provider.

VIII. MISCELLANEOUS PROVISIONS

8.0 Amendments. Provider agrees to be bound by any amendment to this Agreement or the policies and procedures as

posted on the Dentegra website for contracted Providers, effective forty-ve (45) days after notice of such amendmen

is sent to Participating Providers. If Provider does not wish to be bound by such amendment, Provider shall notify

Dentegra of his/her intent to terminate this Agreement within the 45-day notice period. Provider shall comply with any

amendment required by law until the effective date of termination. The foregoing notice requirements shall not apply

to amendments agreed to by mutual written consent of the parties or to amendments required for compliance with

applicable law and regulations.

8.1 Governing Law. This Agreement shall be governed, construed and enforced in accordance with the laws of the state

where the Provider is located and the United States of America, as amended, and the regulations adopted thereunder

including but not limited to those enforced by a state insurance regulatory agency. Any provisions required to be

included in this Agreement by state or federal law or by regulatory agencies with jurisdiction over Dentegra shall bind

Dentegra, Provider and each Rendering Professional whether or not expressly provided in this Agreement. Provider

acknowledges that this Agreement may be subject to approval by such regulatory agencies and may be amended by

Dentegra, as set forth in Paragraph 8.0, in order to comply with applicable law and regulations.

8.2 Incorporation by Reference. All exhibits, addenda and attachments to this Agreement, including Dentegras policies

and procedures referenced in Section 3.2, are an integral part of this Agreement and are incorporated in full herein by

this reference as if they are set forth at length.

8.3 Entire Agreement. This Agreement, contracted fee schedules, appendices, and amendments hereto, contain all theterms and conditions agreed upon by the parties regarding the subject matter of this Agreement and supersede al

prior agreements, either oral or in writing, with respect to the subject matter hereof. Notwithstanding the foregoing, this

Agreement is not intended to supersede separate agreements that may be entered into with Dentegra for participation in

other provider networks.

8.4 Independent Contractor Relationship. The relationship between Dentegra and Provider is that of independen

contractors. Provider, Rendering Professionals, and their respective employees and agents are not nor shall they

be construed to be employees or agents of Dentegra. Dentegra, its employees and agents are not nor shall they be

construed to be members, partners, employees or agents of Provider.

8.5 Indemnication. Dentegra and Provider shall each agree to defend, indemnify and hold harmless the other party

and its directors, ofcers, employees, afliates and agents against any claim, loss, damage, cost, expense or liability

arising out of or related to the performance or nonperformance by the indemnifying party or their respective employees

or agents under this Agreement.

8.6 Assignment. This Agreement, being intended to secure the personal services of Provider, shall not be subcontracted

assigned, transferred or pledged in any way by Provider and shall not be subject to execution, attachment or similar

process, except that Dentegra may assign this Agreement and its rights, interests and benets hereunder to any

Dentegra parent company, afliate or related entity.

8.7 Disputes. Except as otherwise provided in this Agreement, disputes between Dentegra and Provider arising out of this

Agreement shall be rst resolved through the provider dispute resolution procedure described on the Dentegra website.

If the provider dispute resolution procedure described above does not resolve the dispute, such dispute shall be subjec

to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association

(AAA), and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction. The



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initiating party shall give written notice to each other party of its demand to arbitrate on a form provided by the AAA, which

notice shall contain a statement setting forth the nature of the dispute, the amount involved, if any, and the remedy sought

and shall le at any regional ofce of the AAA three copies of the notice, together with the appropriate ling fee required by

the AAA. Arbitration hearings shall be held in a regional AAA ofce unless otherwise agreed upon between Dentegra and

Provider. Such obligations are not terminated upon termination of this Agreement by rescission or otherwise. Any demand

for arbitration shall be submitted within twelve months from the date of the action that is the subject of the arbitration or pee

review.

8.8 Notices. Any notice required under this Agreement to either party shall be sent to that partys address of record by

United States mail (postage prepaid, return receipt requested) or by overnight delivery. Any notice sent by U.S. ma

shall be deemed to have been served upon and received by the addressee seventy-two (72) hours after the notice has

been deposited in the U.S. mail. Any notice sent by overnight delivery shall be deemed to have been served upon and

received by the addressee the next business day. Either party may change the place to which notice is being sent by

giving written notice to the other of any change of address.

8.9 Signatures. The signatories hereto represent and warrant that they have read the Agreement, understand it and are

authorized to execute it on behalf of their respective principals or co-owners.

IN WITNESS WHEREOF, each of the undersigned has individually executed (in the case of an individual provider) or has

caused this Agreement to be executed by its duly authorized representative (in the case of a dental partnership, professiona

dental corporation, dental clinic, etc.) as of the date(s) written below.

Dentegra Insurance Company or

Legal name of provider/business entity Dentegra Insurance Company of New England

IRS Tax Identication Number (TIN)

Authorized signature Daniel W. Croley, DMD

Print name of person signing

Vice President, Network Development

Title (if applicable) of person signing

Date

Practice Location*

Doing Business As (DBA) name

Address City State ZIP

Telephone number Fax number Ofce email address

Mailing Address (if different from practice location)

Address City State ZIP

Telephone number Fax number Ofce email address

*If this agreement applies to more than one practice location, please attach a separate sheet with complete information fo

each of the additional practice locations.

Please return this entire signed original agreement and the other Provider forms. Once the participation process is complete

you will receive written notice.


( ) ( )

( ) ( )


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#70430 Copyright 2012 by Dentegra Insurance Company. All rights reserved8

We require the following information for contracting and IRSincome reporting purposes. Please resubmit this form any timeyou change practices, enter a new partnership, are issued a

new tapayer identification number, etc.

Please fill out form completely.

1) IRS Tapayer Identification Number

2) Legal name of the person, partnership or business (Payee)in which the above TIN (item #1) was issued by the IRS.If this does not match the IRS records exactly, payments toyou may be subject to penalties and backup withholding.*

3) Business name, if different from above (Doing Business As name)

4) License number

5) Dentist name

6) Practice location

City

State ZIP

Phone # ( )

7) Mailing address (if different from practice location)

City

State ZIP

Phone # ( )

8) Type of business entity: Individual/Sole Proprietor

Corporation Partnership

Other (please specify)

CertificationI certify under penalty of perjury that:

The Tax Identification Number and Payee Name I haveprovided is correct;

The Payee is not subject to backup withholding; and

The Payee is a U.S. person (U.S. citizen or resident;partnership, corporation, company or association; or anynon-foreign estate or trust).

Cross out the second bullet if the Payee has been notified by theIRS that it is currently subject to backup withholding.

Signature

Date

Please return this form to:

Dentegra Insurance CompanyATTN: Contracting and Adminstration100 First Street, M/S 5-JSan Francisco, CA 94105

TAxPAYER IDENTIFICATION NUMBER (TIN) REQUEST FORM

Purpose of TIN Request FormWe are required to file an information return with the IRS and musobtain your correct TIN to report income paid to you. Furnishing

your correct taxpayer information and making the appropriatecertifications will prevent certain payments from being subject tobackup withholding.*

We use this form as a substitute for the IRS Form W-9 (Request forTaxpayer Identification Number and Certification). Please refer toForm W-9 and its instructions if you require additional information.

*What is Backup Withholding?Businesses making certain payments to you are required towithhold and pay to the IRS 28% of such payments under certainconditions. This is called backup withholding. If you provide thecorrect TIN and name combination and make the appropriatecertifications, your payments will not be subject to backupwithholding. Payments you receive will be subject to backupwithholding if: (1) You do not furnish your TIN to the requester,

(2) The IRS notifies the requester that you furnished an incorrectTIN or name, or (3) You do not certify your TIN.

See IRS Form W-9 regarding exemptions from backup withholding.

Specific Instructions for Individuals and Sole ProprietorsIndividual payees must generally provide their SSN as their TINand the name shown on their social security card on line 2. Ifyou have changed your last name, for instance, due to marriage,without informing the Social Security Administration of the namechange, please enter the name shown on your social security cardon line 5 and your new name on line 2.

Sole proprietors must furnish their individual name and SSN, whichis preferred by the IRS, or employer identification number (EIN)as their TIN. Enter your name(s) as shown on your social securitycard and/or as it was used to apply for your EIN on Form SS-4.

You may also enter your business name or doing business asname on line 3.

PenaltiesFailure to Furnish TIN. If you fail to furnish your correct TIN, youare subject to a penalty of $50 for each such failure unless yourfailure is due to reasonable cause and not to willful neglect.

Civil Penalty for False Information with Respect to Withholding.If you make a false statement with no reasonable basis that results inno backup withholding, you are subject to a $500 criminal penalty.

Criminal Penalty for Falsifying Information. Willfully falsifyingcertifications or affirmations may subject you to criminal penaltiesincluding fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violationof Federal law, the requester may be subject to civil and criminal

penalties.Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to furnishyour correct TIN to businesses that must file information returns withthe IRS to report income paid to you. The IRS uses the numbers foridentification purposes and to help verify the accuracy of your taxreturn. The IRS may also provide this information to governmentalagencies to carry out tax laws. The IRS may also disclose thisinformation to combat terrorism.

You must provide your TIN whether or not you are required tofile a tax return. Payers must generally withhold 28% of taxablepayments to a payee who does not furnish a TIN to a payer.Certain penalties may also apply.

EDentegra 3052 #70382 (rev. 9/12


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CONFIDENTIAL

CREDENTIALING INFORMATION FORM

This form must be completed by the contracting dentist and each associate dentist treating enrollees. Your responses on this form will

be used to determine whether you meet the eligibility criteria for participation in the network. Treating dentists must maintain eligibility

throughout the term of their participation.

Last Name:

Other name used:

qDDS

Date of Birth:

Dental School: Year Graduated:

Year Graduated:Specialty School (if applicable):

Name: Address:

qDMD

qGeneral Dentist

qPedodontist

Are you currently Board Certied? q Yes qNo If yes, indicate which Board

List hospital for which you have privileges: (List any additional hospitals on back.)

qOrthodontist

qEndodontist

qOral Surgeon

qPeriodontist

qProsthodontist

qMale qFemale qDentist Social Security #

qOther qNPI Number qIndicate Type

First Name: Middle Initial:

(DOB is Mandatory) (SS# is Mandatory here not Tax ID or NPI)

1. Provider Information

Copies of the following documents are required - Copies must be clear, legible and current

Dental License #:

DEA Certicate #:

Prof. Liability Ins. Co.

Liability Limits: (Each Claim)

NPI#:

(Aggregate Claim)

(If assigned and not previously submitted)

State: Exp. Date

DEA Exp. Date:

Policy #:

Policy Exp. Date:

Practice Name:

Practice Address:

City:

Contact Person:

Practice Phone Number:

Controlled Substance Certicate #:

Do you contract with Medicaid and/or CHIP? q Yes qNo

If applicable:

Practice Fax Number:

E-mail Address:

State: Zip:

Exp. Date:

TEXAS ONLY:

TPI# (if applicable)

Practice owner/managing dentist -

submit current copy of X-ray Certicate of Registration.

Page 1 of 4Form #PADCU-01 (Rev. 9-12)

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#70430 Copyright 2012 by Dentegra Insurance Company. All rights reserved10

A complete copy of this form (Credentialing Information Form) for all dentists at the practice

A copy of each dentists current state license

A copy of each dentists DEA certicate

A copy of the declaration page of each dentists 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 process required

A signed copy of the enclosed form (Release to Produce Additional Certicate of Insurance Coverage) for each dentist

q

q

q

q

q

q

q

2. Dental Work History for the Past Five Years

3. Provider Checklist

You must list a complete work history for the past ve years including dates. Please provide an explanation of any work gaps greater

than six months during the past ve (5) years.

1.

2.

3.

4.

5.

Date:

Date:

Date:

Date:

Date:

Please note, we must receive the following documents from you in order to process your application:

Date Stamp

Page 2 of Form #PADCU-01 (Rev. 9-12)

Contracting and Administration Department

100 First Street, M/S 5-JSan Francisco, CA 94105Fax 415-512-9482


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#70430 Copyright 2012 by Dentegra Insurance Company. All rights reserved.

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q q 1.

Yes

Yes

No

No

q q 2.

q q 3.

q q 4.

q q 5.

q

q

q

q

q

q

q

q

q

q

q

q

6.

7.

8.

9.

10.

11.

Have you ever been denied membership, or renewal of membership, or been subject to disciplinary proceedings for a medical, dental

or ethical reason by any dental/professional organization?

Are you unable to perform any procedures within the scope of privileges and duties in your position as a health care provider, with

or without reasonable accommodations required by the Americans With Disabilities Act, within accepted standards of professional

performance and without posing a direct threat to patients?

Do you currently, or did you in the last ve years, engage in the unlawful use of illegal drugs, including the improper use of prescription

drugs?

Do you have any felony or misdemeanor charges pending against you or have you ever been convicted of a felony, or pleaded nolo

contendere to a felony?

Have you been involved in ANY malpractice (or any other civil) claims/lawsuits, settlements or judgments within the last fve years?

If yes, please provide detailed information on a separate sheet of paper including: docket number of the case, location of

the court, names of the parties, plaintiff(s) and defendant(s), dates of the incident(s), description of the incident(s), your

involvement, current disposition, and the amount of the settlement(s).

Do you follow Center for Disease Control Guidelines for Infection Control in Dental Health-Care Settings and observe all applicable

laws and regulations related to the practice of dentistry including, but not limited to, those dealing with infection control and

employee safety in the work place?

Do you have current professional malpractice insurance coverage and agree to maintain continuous, uninterrupted coverage while

either a contracted dental provider for the Plan or an associate of a contracted dental provider? Please note that under the terms of

participation that you further agree to notify the Plan immediately of any policy cancellation, lapse in coverage, reduction in coverage

maximum(s) or claims made.

q

q

q

q

12.

13. Is practice accepting new patients?

Are your privileges or memberships at any hospital, institution (Military service) and/or HMO currently under investigation or have

they ever been denied, suspended, reduced or not renewed?

Has your status as a provider ever been denied, suspended, canceled or sanctioned by any municipal, state, federal or any other

governmental agency (e.g. Medicare, Medicaid or Denti-Cal) HMO, EPO, PPO or other prepaid health plan?

Has your Federal and/or State DEA license or applicable drug license ever been denied, suspended, canceled or not renewed, or

subjected to any disciplinary action?

Has your license to practice in any jurisdiction, whether past or still pending, been denied, restricted, limited, suspended, revoked,

not renewed, placed under probation, subjected to disciplinary action, or otherwise sanctioned, limited or curtailed?

Has your professional liability insurance ever been denied, suspended, revoked, canceled, or not renewed?

TO EXPEDITE THE CREDENTIALING PROCESS, THIS PAGE MUST BE COMPLETED IN ITS ENTIRETY.

4. Professional Attestation and Questions

I. Credentialing History (Please answer questions 1 - 10 below. For any Yes answer, explain on a separate piece of paper.)

Dentist First Name (Please print)

Dentist Date of Birth Dentist License Number State Issuing License

Middle Initial Last Name

II. Compliance & Malpractice Insurance (Answer questions 11, 12 and 13. For any NO answer, explain on a separate sheet of paper.)

I authorize the Plan to consult with professional liability carriers, and other persons or entities to obtain information concerning my professional

qualications including competence, ethics and other qualications. I, the undersigned, hereby certify that the information requested by the Plan

and provided herein, is truthful, correct and complete in all respects. I further understand that the intentional submission of false or misleading

information or the withholding of relevant information is grounds for denying participation or termination as a participating dentist with the dental

plan. The undersigned hereby agrees to notify the Plan immediately of any changes in the above information.

Upon request, practitioners have the right to review the information in their credentialing le and to ask for correction of any error or omission

believed to be signicant. To be accepted, any such requests must be submitted in writing to the Provider Administration department within 365

days of the practitioners last submission of completed credentialing forms.

Dentist Signature (no signature stamps): Date:


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#70430Copyright 2012 by Dentegra Insurance Company. All rights reserved.

12

Release to Produce

Additional Certicate of Insurance Coverage

I hereby request that ____________________________________________, from which I purchase my

liability insurance, is authorized to produce an additional certicate of insurance coverage for the Contracting

and Administration Department, 100 First Street, M/S 5-J, San Francisco,CA 94105. This certicate can be

mailed at each renewal until otherwise notied.

Doctor Signature

Print Name

Policy Number

License Number

Date

Date

Contracting and Administration Department

100 FirstStreet, M/S 5-J


Fax 415-512-9482



15/18


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1. Name of practice (doing business as): ________________________________________________________________________________________________________

Street address: ______________________________________________________________________________________________________________________________________

City: _________________________________________________State: __________________ ZIP: __________________ Office phone: ___________________________

2. Dentist name:

First name Initial Last name

License number: _________________________________________________ Male Female

3. Dental school #1: __________________________________________________________________________________________ Graduation year: ___________________

Dental school #2: __________________________________________________________________________________________Graduation year: ___________________

4. Type of practice:

Solo Clinic Community clinic

Dental school Mobile clinic Other_________________________________________

Group Practice (Attach a list of all dentists that will be credentialed to treat Dentegra patients)

5. Your practice's web site address: ______________________________________________________________________

6. Special services provided in your office (Please check all that apply):

Accessible by public transit Saturday hours Treats disabled adults

Early morning appointments (before 9 a.m.) Sunday hours Treats disabled children

Evening appointments (after 5 p.m.)

Treats children

7. Wheelchair accessibility

Your office can be listed as accessible to persons who use wheelchairs if it meets certain functional accessibility guidelines.

Please verify that your office meets each of these guidelines:

A. Doorways and entrances to the building and office are at least 32" wide. Yes No

B. Hallways are at least 36" wide, with sufficient room for a wheelchair to make necessary turns. Yes No

C. There is enough room for a wheelchair user to travel from the waiting area to the treatment area. Yes No

D. The restroom has an accessible doorway, at least 48" of clear floor space, and grab bars to allow

transfer to/from a wheelchair. Yes No

E. The building or office is accessible by more than stairs or a steep slope. Yes No

F. If the building has parking facilities, there are parking spaces reserved for people with disabilities. Yes No

Note: Your office will be listed as wheelchair accessible only if it meets all of these accessibility guidelines.

EDentegra 3053 #70383 (rev. 9/12

OFFICE INFORMATION FOR ONLINE DENTIST DIRECTORY

(Continued on next page

1


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8. Language spoken other than English in this office:

If you need additional pages, please copy this form and attach.

Name:

Dentist Staff

Language(s) spoken other than English:

Name:

Dentist Staff


Name:

Dentist Staff


Name:

Dentist Staff


Name:

Dentist Staff


Please provide your contact information should we need to clarify any statements or data before updating Dentegra

Insurance Companys online dentist directory.

Contact name:__________________________________ Practice Manager: ________________________________

Telephone number: (_____)_______________________ Telephone number: (_____)_________________________

Email:________________________________________ Email:__________________________________________

Please return this form to:



100 First Street, M/S 5-J


14


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Complete and sign the agreement on page 7 and all

forms on pages 8-14. Please make a copy of this booklet

for your records and return the entire original booklet to:



100 First Street M/S 5J

San Francisco, CA 94105Donotdetach


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100 First Street


dentegra insurance application

Documents