Provider ManualYour Careington Dental Network Solution

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Welcome to your Careington dental network solution!

Thank you for partnering with Careington to grow your practice. Our dental networks are operated by Careington International Corporation. At Careington, we pride ourselves on designing thorough, comprehensive fee schedules that are beneficial to providers and members. The various administrative methods allow your office to serve fee-for-service (POS) discount plan consumers, traditional insured (PPO) consumers or both!

Table of Contents

3 Getting Started4 Careington Contact Numbers6 Overview of Dental Plans7 Discount Networks - POS8 Claim Networks - PPO9 Regional Dental Plans 10 ID Cards11 Credentialing Process12 Cultural Sensitivity

CIC_ProvMan1216_Nationwide

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Getting Started

As a Careington dental network provider, you have access to a dedicated provider relations team, a comprehensive provider portal and a 24/7 Interactive Voice Recognition service that’s available 365 days a year to help you verify member eligibility or to answer any questions your office may have.

Provider Portal www.careington.com/dentists

Here are some of the features available through the portal:

Verify patient eligibility online.

View your active providers and their plan acceptance details.

Download all necessary Careington forms, including fee schedules.

Learn about new, valuable offerings exclusive to Careington providers and office staff.

You must first register your practice location in order to access the portal. Practices with multiple locations must register each location individually.

To register, please visit www.careington.com/dentists and enter the following ID:

Your ID: [location ID number]

Once you have registered, if you decide not to use the ID provided, please print the permanent ID you create here, for future reference and for new staff to locate it easily: ______________________.

If you have any questions regarding use of the provider portal or are in need of temporary IDs for additional locations, please contact our Quality Assurance team at 800-441-0380 option. 8.

Corporate Website www.careington.com

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Careington Contact Numbers

24-Hour Patient Verification Number ...................................(888) 901-3705 available 7 days a week

Direct Customer Service Line ...................................................(800) 290-0523

Need to add a new provider, location or plan?

Recruiting Division ..................................................................................(800) 441-0380 option. 6 Monday – Thursday7 a.m. – 6 p.m. CT

Friday 7 a.m. – 12 p.m. CT

Need Credentialing documents or status for a new or existing provider?

Credentialing Division ..................................................................................(800) 441-0380 option. 7 Monday – Friday 8 a.m.– 5 p.m. CT

Need additional information regarding plan design, network logos, or updating office information?

Provider Relations Division .....................................................................(800) 441-0380 option. 8 Monday – Friday 8 a.m.– 5 p.m. CT

Network Development – Fax Number ................................... (800) 247-4450

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Careington ensures that its provider network is comprised of dentists who are at the top of their profession.

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Overview of Dental Plans

Discount Networks – POS

Careington started with a fee-for-service (POS) network which allows members to pay at the time of service and receive discounts that make treatment plans more affordable. This POS network encourages more consistent visits to the dentist.

Logos to look for to confirm a POS administrative design:

Claim Networks – PPO

Careington also offers claims- based networks known as the PPO networks. The ID cards presented by members in these plans will include information on the claims payor and where to submit claims. Claims submission information is typically on the back of the ID Card.

Logos to look for to confirm the network is a PPO network and that a claim should be submitted:

PPO

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Discount Networks - POS

A simple administration process is the hallmark of our discount fee-for-service (POS) plans.

• Administration: Patient receives a discount and pays balance in full at the time of service.

• General Dentist fees: Charge patient according to the logo on the patient’s ID card and your corresponding discount fee schedule enclosed.

• Specialist fees: Charge patient according to the logo on the patient’s ID card and your corresponding contracted percentage discount off your customary office fee, based on the network presented.

Care 500 Plan — This plan is quite attractive to consumers, and has proven to be a great tool regarding acceptance of treatment plans and more frequent and consistent visits by members. These fee schedules are labeled 501 through 508 and are assigned by state. A flat 20% discount off UCR will be offered on any procedure performed by a Specialist or not listed on the fee schedule used by General Dentists. Lab fees are not subject to discounts and can be charged as normal.

Care Series POS Plan — This plan offers the largest population of Careington members. These fee schedules are labeled the CI-1 through the CI-12 and are assigned by the office’s three-digit zip code. A flat 20% discount off UCR will be offered on any procedure performed by a Specialist or not listed on the fee schedule used by General Dentists. Lab fees are not subject to discounts and can be charged as normal.

Care Platinum POS Plan — Our Platinum fees are flexible to meet your practice needs. The fee schedules are labeled the CP-1 through the CP-99 and are assigned by the office’s three-digit zip code. A flat 15% discount off UCR will be offered on any procedure performed by a Specialist or not listed on the fee schedule used by General Dentists. Lab costs have been figured into the fee schedule amounts and should not be charged additionally.

Maximum Care Plan — Careington created a network that opens your office to the largest number of potential patients. If you have questions on which schedule to follow, please contact our Provider Relations department.

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Claim Networks-PPO

Careington administers PPO networks for traditional indemnity or self-funded programs. Providers submit their usual and customary rate (UCR) (less any applicable co-payments) to the third party administrator or payor listed on the patient’s ID card for payment, and the claim is repriced according to the contracted fee schedule for General Dentists or discount percentage for Specialists.

• Administration: Submit claim for payment (less any applicable co-payments) to the third party administrator listed on the patient’s ID card.

• General Dentist fees: Collect patient’s applicable co-payment and submit your office’s UCR. The claim will be repriced according to your contracted PPO fee schedule enclosed.

• Specialist fees: Collect from patient any applicable co-payment and submit your office’s UCR. Your contracted flat percentage discount will be applied when the claim is processed.

Care Series PPO Plan — This plan offers the largest population of Careington members. These fee schedules are labeled CI-1 through CI-12 and are assigned by the office’s three-digit zip code. A flat 20% discount off UCR will be offered on any procedure performed by a Specialist or not listed on the fee schedule used by General Dentists. Lab fees are not subject to discounts and can be charged as normal.

Care Platinum PPO Plan — Our Platinum fees are flexible to meet your practice needs. The fee schedules are labeled CP-1 through CP-99 and are assigned by the office’s three-digit zip code. A flat 15% discount off UCR will be offered on any procedure performed by a Specialist or not listed on the fee schedule used by General Dentists. Lab costs have been figured into the fee schedule amounts and should not be charged additionally.

Maximum Care — Careington has created a network that opens your office to the largest number of potential patients. The beauty is that you are reimbursed by either the Care Series PPO or Care Platinum PPO rates. You submit the claim and you will receive the same rates you have come to expect!

PPO

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Regional Dental Plans

Careington has three regional plans, including two PPO plans and one discount fee-for-service (POS) plan.

Emblem Prime Plan (PPO)Administration: Submit a claim for payment (less any applicable co-payment) to the third party administrator listed on the patient’s ID card.

General Dentist fees: Collect patient’s applicable co-payment and submit your office’s usual and customary rate (UCR). The claim will be repriced according to your HIP Prime fee schedule enclosed (if this plan was selected).

Specialist fees: Collect patient’s applicable co-payment and submit your office’s UCR. Your contracted 20% discount will be applied when the claim is processed.

Lab costs have been figured into the fee schedule amounts and should not be charged additionally.

Availability: Only available in CA, CT, DC, FL, GA, MA, MD, MO, NC, NJ, NY, OH, PA, SC, VA, AND WV.

Emblem VIP Plan (POS)Administration: Patient pays balance in full at the time of service

General Dentist fees: Charge patient according to your HIP fee schedule enclosed (if this plan was selected).

Specialist fees: Charge patient 20% less than your customary office fee.

Lab costs have been figured into the fee schedule amounts and should not be charged additionally.

Availability: Only available in CA, CT, DC, FL, GA, MA, MD, MO, NC, NJ, NY, OH, PA, SC, VA, AND WV.

Careington-Humana Plan (FL)Administration for General Dentists (PPO): Submit a claim for payment to the third party administrator listed on the patient’s ID card. Humana will make payment for the insured’s covered services.

Administration for Specialists (POS): Charge patient 20% less than your customary office fee and collect payment at the time of service.

Lab costs have been figured into the fee schedule amounts and should not be charged additionally.

Availability: Only available in FL.

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ABCInsurance CompanyP.O. Box 2568, Frisco, TX 75034

For claims and eligibility questions, call (888) 888-8888

The individual named has enrolled in the Insurance Program of the Group identified above. This card is for identification purposes only and is not a guarantee of coverage. For information concerning benefits, you may communicate with the above address.

ID cards

Discount CardBelow are sample ID cards.

Logo

Phone number included for office to verify eligibility

Clear indicator this is a POS network

Contact information for the payor will be on the ID card

Claim Card

(800) 290-0523 www.careington.com

(800) 290-0523

Member: <John Doe>Member #: <123456789> Group ID: <Group Code>Subscriber ID: <123456789> Effective Date: <00/00/00>

Member: <John Doe>Member #: <123456789> Group ID: <Group Code>Effective: <00/00/00>Coverage: <123456789>

ABCInsurance Company

THIS IS NOT INSURANCE.

THIS IS NOT INSURANCE. IT IS A DISCOUNT PROGRAM

Careington Member Services (800) 290-0523 | www.careington.com

www.careington.com

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Credentialing Process

Careington ensures that its provider network is comprised of dentists who are at the top of their profession. In order to be an active provider in Careington’s dental network, it is necessary to present specific documentation for credentialing purposes.

Initial CredentialingInitial credentialing takes place when the provider agreement is initially submitted to Careington for consideration. At this time, it is necessary for the provider to submit the following documents:

� Signed and dated attestation questionnaire � Copy of his/her current dental license � Copy of his/her current malpractice insurance declaration page with coverage amounts

of 200,000/600,000 in all states except New York, where they must maintain amounts of 1,000,000/3,000,000

� Copy of his/her current DEA certificate or signed explanation as to why this certificate is not needed

� Copy of his/her current state-mandated controlled dangerous substances certificate or signed explanation as to why this certificate is not needed

� Last 5 years of work history, if applicable

RecredentialingThe recredentialing process happens at 3-year intervals following the completion of the initial credentialing phase. During this phase, we verify the information on file for accuracy as well as:

� Signed and dated attestation questionnaire � Valid state license verified � DEA certificate verified, if applicable � Copy of his/her current malpractice insurance declaration page with coverage amounts

of 200,000/600,000 in all states except New York, where they must maintain amounts of 1,000,000/3,000,000

Learn MoreCall our network credentialing specialists to learn more about Careington’s credentialing process.(800) 441-0380 option. 7

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Cultural SensitivityA limited English proficient enrollee is an enrollee who has an inability or limited ability to speak, read, write or understand the English language on a level that permits that individual to interact effectively with health care providers.As established by your participating provider agreement, you must provide Covered Services in a culturally competent manner to all health plan patients, including those with limited English proficiency and diverse cultural and ethnic backgrounds.If you participate in the network for our Medicare Advantage products, you must comply with the following additional requirements (as applicable) for services you provide to our Medicare Advantage enrollees.

• You may not discriminate against enrollees in any way based on health status.

• You must make sure that enrollees have adequate access to Covered Services.

• You must make sure that your hours of operation are convenient to enrollees and do not discriminate against enrollees and that medically necessary services are available to enrollees 24 hours a day, 7 days a week.

• You may only make available or distribute plan marketing materials to enrollees in accordance with CMS requirements.

• You must provide services to enrollees in a culturally competent manner, taking into account limited English proficiency or reading skills, hearing or vision impairment and diverse cultural and ethnic backgrounds.

• You must cooperate with our procedures to inform enrollees of health care needs that require follow-up and

provide necessary training to enrollees in self-care.

• You must provide Covered Services in a manner consistent with professionally recognized standards of health care.

• You must make sure that any payment and incentive arrangements with subcontractors are specified in a written agreement, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards.

• You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the Medicare Advantage Program, and all information determined by CMS to be necessary to assist enrollees in making an informed choice about Medicare coverage.

• You must cooperate with our processes for notifying enrollees of network participation agreement terminations.

• You must comply with our Medicare Advantage medical policies, quality improvement programs and medical management procedures.

• You must cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance and other indicators as specified by CMS.

• You must cooperate with our procedures for handling grievances, appeals and expedited appeals.

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Notes

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7400 Gaylord Parkway | Frisco, Texas 75034Toll-Free: (800) 441-0380

www.careington.com