Credentialing and Contracting Instructions
What’s required?
All Dentists who want to enroll with DentaQuest must be credentialed AND contracted before you can begin treating
members. To get credentialed you need to submit a completed credentialing application.
 If the office you will be participating with is not contracted, one contract for the business (i.e. Tax ID), listing all
participating providers and a W-9 is required.
 If you are credentialed with DentaQuest and the office you will be participating with is already contracted with
DentaQuest please simply supply a letter on company letterhead requesting the provider to be added to the
existing contract. Be sure to include the business name, Tax ID, and applicable office location(s).
 Please note some states require additional forms that can be found on our website.
All enrollment documents can be found at: www.dentaquest.com Dentists[State]Dentist Page.
Send enrollment documents to: Email: [email protected] | Fax: 262.241.7401
How do I get Credentialed and Contracted?
There are a couple of ways to submit a credentialing application to DentaQuest. Please select one of the following options
to begin the enrollment process.
Option 1: Complete DentaQuest’s Initial Provider Credentialing Application along with the applicable Provider
Service Agreement, W-9, Disclosure of Ownership, and state required forms.
Option 2: Submit your existing CAQH application. You can do this by sending us the applicable Provider Service
Agreement, W-9, Disclosure of Ownership, and state required forms along with your full name and CAQH ID using
the chart
Option 3: Begin an online application with CAQH. To do this complete and send back the information in the below
chart along with the applicable Provider Service Agreement, W-9, and Disclosure of Ownership, and state required
forms. DentaQuest will then roster you with CAQH. A CAQH Quick Reference Guide is available at
https://upd.caqh.org/oas/UPDQuickReferenceGuide20120820.pdf.
Important Tips and Reminders

Submit your application as soon as possible. but do not submit without a Medicaid ID (if applying for a Medicaid
program).

Credentialing Contact Information – Name, phone number, email address.

Required Documents- Check that all the information you provide is current (e.x. malpractice insurance). If any
items are missing DentaQuest will be contacting the credentialing contact you list on the application.

Submit application with all applicable sections completed. If something does not pertain, indicate N/A. Do not
leave any fields blank.

Questionnaire – please answer each question either yes or no. N/A is not an acceptable answer on the CAQH
application. For any question you answer Yes, a detailed explanation including a summary of the situation and
the resolution is required.

Disclosure of Ownership is required, but is not included in the CAQH application. If you are submitting a CAQH
application be sure to send us our Disclosure of Ownership.

Certification, Statements and Signature Page – read the statement carefully. Sign and date this page. Signature
may not be older than 120 days old.
CAQH Enrollment Instructions
What is CAQH?
The CAQH (Council for Affordable Quality Healthcare) offers a single credentialing application and an online data base
that contains information necessary for insurance companies to credential a provider. This allows providers to submit and
maintain their credentialing information at one location rather than filing with many organizations. There is no cost to file
an application with CAQH and it can be completed online.
If you already have an active application with CAQH simply fill-out the below chart. DentaQuest will roster you. If
you have not selected the option for all insurance companies to have access to your application you will need to give
DentaQuest access to your application once you are on our roster. Remember to send the appropriate contract, W-9, and
other required documents for your state.
Required Fields
Provider 1
Provider 2
Full Provider Name
Individual NPI
CAQH ID (if app already on
file with CAQH)
If you do not have an application on file with CAQH, but would like to complete an online CAQH application please
fill-out the following chart. Once DentaQuest has the information we add you to our roster on the CAQH website. This
will trigger CAQH to send you an invitation to join CAQH with instructions on how to log-in and begin your application.
Once you have this you can login to https://upd.caqh.org/oas/ using your CAQH ID
Required Fields
Provider 1
Provider 2
Full Provider Name
Degree Type (DDS, DMD)
License Number & Specialty
Individual (Type I) NPI
Date of Birth
Mailing Address
Phone
Fax
Email (Dentist’s Personal &
Credentialing Contact)
 All enrollment documents can be found at: www.dentaquest.com Dentists[State]Dentist Page.
 Send enrollment documents to: Email: [email protected] | Fax: 262.241.7401
 A CAQH Quick Reference Guide is available at https://upd.caqh.org/oas/UPDQuickReferenceGuide20120820.pdf.
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Application and Contract Checklist
Dear Provider:
It is our intention to provide a streamlined credentialing process. To guide you through the process, prior to
sending us your application, please use the checklist below to ensure you have sent us all the required items.
Incomplete applications cannot be processed.
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Email address must be supplied to utilize DentaQuest’s online credentialing and recredentialing – coming soon!
Date of birth – required to begin the credentialing process
You must supply your state issued Medicaid ID, where applicable.
Specialty (i.e. General Dentist, Pediatric Dentist, Oral Surgeon, etc.)
State License section must be completed or a copy of the license provided. Providing a copy of the license will speedup the credentialing process:
CDS and/or BNDD – enclose a copy. The state listed on the CDS and/or BNDD, must match the state where you are
requested to be credentialed.

Complete DEA section. A DEA is required for each state where you practice. A disclosure is required if you do not hold
a DEA.
Individual NPI number
Group NPI if W-9 Type is Corporation, LLC, or Partnership (exception: sole proprietor’s with an LLC)
Location Name, address, city, state, zip, phone, fax, email address.

Office Type – Federally Qualified Health Center, Local Health Department, Group Practice, etc.
Credentialing correspondence contact, email address, phone and address, city, state, zip.

American Board Certification – if you hold board certifications, you must list them.
Privilege Information – you must identify hospital(s) at which you have admitting privileges.
Employment History section of application or curriculum vitae—5 year (10 year if providing CAQH application)
history required in month and year format. An explanation of gaps within the last 5 years that are greater than 6 months
is required. Start date at primary location is required.
Education /Training Section – list all institutions and training with the month and year of attendance.
Providers treating Florida members must supply two peer reference letters
Liability Insurance Binder - must not expire within 60 days and must comply with plan limits
Attestation Questions (yes/no section) completed. N/A is not an allowable on the CAQH application. 
If “Yes” to any attestation questions (1-14) please enclose a separate disclosure explanation page
Signed Application - must be hand written, no stamps. Date must be less than 120 days old.
Disclosure of Ownership must be completed.
State required form(s) in your application packet
Contract and W9 Completeness Checklist
Contract signed and dated
All Applicants must be listed on contract
W9 signed and dated
Contract Street Address, City, state, and Zip
Entity Name on the contract must match line 1 of the W-9 and TIN on contract must match W-9.
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Page 2
12121 North Corporate Parkway, Mequon, WI 53092
(262) 241-7140 or (800) 417-7140
Fax (262) 241-7401
**INCOMPLETE APPLICATIONS WILL DELAY THE CREDENTIALING PROCESS**
1.
2.
3.
4.
5.
6.
Please print or type ALL responses.
If you need additional space to complete a section, please attach additional sheets.
If a question does not apply, please indicate “N/A”.
If you answer “yes” to any questions in the Questionnaire Section, you MUST attach a detailed
explanation.
Incomplete applications will not be accepted. Every field must be completed. If an item is not
applicable, please indicate “N/A.”
Please complete all sections with additional focus on those sections or questions with an *.
PLEASE REMEMBER:
PROVIDER CANNOT BEGIN TO TREAT MEMBERS UNTIL A WELCOME LETTER
FROM DENTAQUEST IS RECEIVED
DentaQuest Credentialing Process
Credentialing is the process of verifying credentials (i.e. training, licensing, hospital affiliations) of potential providers by primary sources.
DentaQuest takes pride in its network of providers and is proud to say that all providers are credentialed following the guidelines of the National
Committee for Quality Assurance (NCQA) to ensure our members that they are receiving the best quality care possible. Using NCQA guidelines for
credentialing ensures an organization that the providers affiliated with their panel are the best in the dental field.
PLEASE Check One:
 New Provider, New Location
 Adding Additional Location
 New Provider, Existing Location
Other
Please add _______________________ to current contract under ______________________________
(Provider Name)
(Entity Name)
With Tax ID# ______________________________.
PROVIDER APPLICATION
GENERAL INFORMATION
Last Name
Degree
First Name
Middle Initial
* Provider Social Security Number
*Date of Birth
*Provider Personal E-mail Address
(MM/DD/YY)
Provider Gender
Provider Race/Ethnicity
Other
Medicaid ID
Specialty
Please list Dental, Medical and Anesthesia licenses for all states you currently hold or previously held a license.
License Type
License Number
License State
Effective Date
Expiration Date
License Type
License Number
License State
Effective Date
Expiration Date
License Type
License Number
License State
Effective Date
Expiration Date
DEA Number ____________________________ Expiration Date ___________________________ Note: A DEA license is required for each state
you practice in.
Please Check the Schedules that apply on your DEA certificate:
Schedules If you do not hold a DEA license, please provide an explanation as to why and the name of the
provider who will prescribe on your behalf, should a patient require medications.
________________________________________________________________________________________________________________________
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INDIVIDUAL NPI NUMBER
NPI Number
NPI Type - Individual
NPI Effective Date
Taxonomy Code
OTHER NPI INFORMATION
is indicated on your W9.
Note: ALL non-Sole Providers MUST complete Organizational NPI information below.
GROUP /ORGANIZATION NPI INFORMATION (REQUIRED unless Sole Proprietor is indicated on
your W9)
NPI Number
NPI Type - Group
NPI Effective Date
Taxonomy Code
SUB-PART NPI INFORMATION (Not required)
NPI Number
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
NPI Number
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
NPI Type - Subpart
NPI Effective Date
Taxonomy Code
NPI Number
PRIMARY SERVICE OFFICE INFORMATION
Primary Office Name
Office Contact
Office Phone Number
Primary Office Address
Office Email Address
Clinic
FQHC
Article 28 (NY)
Office Type
City
State
Secondary Office Name
Office Contact
Secondary Office Address
City
Office Fax Number
Zip Code
County
Office Phone Number
Office Fax Number
Office Email Address
State
Clinic
FQHC
Article 28 (NY)
Office Type
Zip Code
County
CREDENTIALING CORRESPONDENCE INFORMATION (address where credentialing
information will be sent)
Credentialing Correspondence Office
Name
Credentialing Contact Name
Correspondence Address
City
Credentialing
Telephone Number
Credentialing
Fax Number
*Credentialing Correspondence E-mail Address
State
Zip Code
BILLING INFORMATION
Federal Tax Identification Name (Name as it appears on Line 1 of W9)
Billing Office Address
Billing Office Contact Name / Title
08012013
Doing business as (if applicable)
City
Telephone Number
Federal Tax Identification Number (TIN)
State
Zip Code
Fax Number
Page 4
Billing information for secondary location if different from Primary Location
Federal Tax Identification Name (Name as it appears on Line 1 of W9)
Federal Tax Identification Number
CRS-1 Identification Number (NM only)
Billing Office Address
City
Billing Office Contact Name / Title
State
Telephone Number
Zip Code
Fax Number
AMERICAN SPECIALTY BOARD CERTIFICATION
Specialty Board(s) by which you are certified
Name
Date Certified
Expiration Date
Recertification Date
PATIENT INFORMATION
Patient
*Minimum Age ______________________________________ Maximum Age ___________________________
HOSPITAL PRIVILEGES
List all Hospitals at which you have admitting privileges:
Hospital Name
Address
City
State
Hospital Name
Address
City
State
Address
City
State
Hospital Name
OFFICE INFORMATION (Not Provider Specific)
Office Hours
Primary
Location
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Office Hours
Secondary
Location
*In the event of an emergency, do you have overage after normal business hours or provide emergency contact information on your office phone or have
any other protocol?
Yes No If yes, Please list your contact information: ___________________________________________________________
__________________________________________________________________________________________________________________________
*Languages spoken at office (check all that apply)
*Does your office provide access to a skilled medical interpreter?
*Are translation services available?
*Is your office handicapped/wheelchair accessible?
*Is your entry way handicapped/wheelchair accessible?
*Is your waiting room handicapped/wheelchair accessible?
*Are your bathrooms handicapped/wheelchair accessible?
*Are your treatment room’s handicapped/wheelchair accessible?
**Do you provide sedation services for members with complex medical or behavioral conditions?
*Does your office accept patient with Special Needs?
If yes check all that apply:
Adult
Child
ADHD
Physically Disabled
Learning Disabled
HIV
AIDS
Paraplegic
Quadriplegic
Seizure Disorders
Cognitive Disability
Mobility Limitations
Autism
Communication Disorders
Behavioral Disorders
Hearing Impaired
Visually Impaired
*Is the office accessible by public transportation?
Number of treatment chairs: __________
Does your office have a computer with internet access?
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Page 5
PROFESSIONAL EMPLOYMENT HISTORY (READ CAREFULLY)
Chronologically list all present and previous work history related to your professional employment within the past five (5)
years (if you graduated less than five (5) years ago work history should be provided starting with your graduation date).
All dates must be in Month and year format.
Please provide a written explanation of any gaps greater than 6 Months.
*What was your start date at your primary location? __________ / __________ / __________ (month/day / year)
Hire Date
(MM/YY)
Termination Date
(MM/YY)
Employer
Location Address
Reason for Leaving
EDUCATION / TRAINING
Professional School Name
City/State
Degree(s)
Date Received
Post Graduate Education- Name
City / State
Type (Residency,
Internship, etc)
Specialty
Beginning / Ending Dates
Post Graduate Education- Name
City / State
Type (Residency,
Internship, etc)
Specialty
Beginning / Ending Dates
PROFESSIONAL REFERENCES – REQUIRED for New Mexico and Florida Providers
Name
Address
Phone
Email
Name
Address
Phone
Email
Name
Address
Phone
Email
PROFESSIONAL LIABILITY (MALPRACTICE) INSURANCE
I am currently covered by the Federal Tort Claims Act
complete the section below with Qualifying Entity information.
Mailing Address
Name of current Carrier
Phone #
If No complete the section below with current malpractice carrier information. If Yes please
Fax #
Policy
#
Effective Date
Expiration Date
Amounts of Coverage: Occurrence/Claim
Aggregate $_____________________
$____________________
Name of Qualifying Entity (Please attach a copy of the Notice of Deeming Action)
Effective Date
08012013
Expiration Date
Coverage Limits
Page 6
QUESTIONNAIRE
Please mark with an X under the yes/no columns for each question. If you answer YES to any of the following questions with the exception of 16 &
17, please provide us with a detailed explanation and attach to the application.
1.
Have you verified through the System for Award Management (SAM.gov) that none of the employees working in you practice(s) are excluded
from participating in Medicaid or Medicare programs?
_____Yes ____Not Applicable, I am not the owner of the Dental Practice as identified on the attached disclosure of ownership form.
YES
NO
____
____
2.
Has your Dental License been limited, suspended, denied, revoked, restricted, subject to probationary conditions, or
have proceedings been instituted against you?
____
____
3.
Have you voluntarily relinquished, reduced, restricted, or otherwise limited your dental license in any jurisdiction?
Note: this includes allowing a license to expire because you no longer practice in a state.
____
____
4.
Have you been reprimanded or disciplined by any State or Commonwealth Department of Regulation and Licensure of
the Dental Examining Board?
____
____
5.
Has your participation for receiving payment under the Medical Assistance, Medicaid, or Medicare program been
suspended or limited or have you voluntarily terminated your participation?
____
____
6.
Have you been convicted of any criminal offenses, pending or otherwise, other than a minor traffic violation?
____
____
7.
Have you had a judgment made against you for alleged malpractice, negligence, or related matters?
pending?
____
____
8.
Have you had any judgments made against you in a professional liability case or has your liability insurer placed any
conditions or restrictions on your coverage or ability to attain coverage?
____
____
9.
Have any litigation settlements been made on your behalf?
____
____
10.
Are you, or have you been, under the treatment for the use of narcotics, barbiturates, alcohol, or other drugs?
____
____
11.
Do you presently have any physical or mental conditions that would adversely affect your ability to provide high
quality professional services? Are there any accommodations that need to be considered? Please list accommodations
below.
____
____
12.
Has your participation with a managed care organization, other health care organization, or hospital privileges been
suspended, limited, or terminated?
____
____
13.
Has your Drug Enforcement Agency (DEA) registration been denied, revoked, suspended, not renewed or have you
voluntarily surrendered, reduced, or limited your DEA registration?
____
____
14.
Are you currently using illegal drugs?
____
____
15.
Do you use any form of protective stabilization without having completed a residency program, a graduate program, or
a Continuing Medical Education (CME) certified course in protective stabilization?
____
____
_____
_____
16.
17.
Are any cases
(NJ provider only are required to complete this question) Are accommodations made for the patient’s cultural and
linguistic needs and are they noted in the patient’s dental record?
(Florida Medicaid Providers only) I attest and affirm that this office maintains a ratio of one FTE per 1,500 active
patients and 500 additional active patients for each FTE licensed dental hygienist up to a maximum of two hygienists
per FTE dentist.

The active patient load is a complete count of all the office’s active patients for all lines of
business and plans (including Medicaid, Medicare and commercial)

An active patient is defines by AHCA as any patient who has been seen by the office two times in
the last year For example, if a patient was seen only one time in the last year they would not be
considered and active patient.

FTE stands for full time equivalent.
Dentist Name: (Please Print) ________________________________________________
08012013
Page 7
CERTIFICATION, STATEMENTS, AND SIGNATURE
I hereby acknowledge that the information provided in this application is material to the determination by DentaQuest whether or not
to execute an agreement with me. I hereby represent and warrant that all information provided herein is true, correct and complete to
the best of my knowledge, and I agree to notify DentaQuest in the event an error is discovered or when new events occur which alter
the validity of any response herein. I hereby authorize DentaQuest to consult with individuals or institutions with which I have been
associated and with others, including but not limited to past and present malpractice carriers, educational institutions, and state
licensing boards, who may have information bearing on my professional competence, character and ethical qualifications and
authorize the release of any such written or oral verification as needed by DentaQuest. I hereby release from liability for any such
entity, institution, or organization that provides information as part of the application process.
I certify that:
*
*
*
*
All parties of material interest have been identified and include no persons or entities with a potential for profit from selfreferral,
All services are provided by and under the “on Premise” supervision of a licensed dentist,
The above information is complete, correct and true to the best of my knowledge,
My malpractice information is current at the time of application and the limits are at or exceed the
minimum amounts required by the Plan and DentaQuest.
Individual Provider Participation Attestation
Attestation to confirm that you have agreed to become a Participation Provider/ Provider Dentist in the DentaQuest provider network,
by means of your or your office’s Provider Agreement with DentaQuest to render services to Members pursuant to the Agreement
with DentaQuest.
Signed by: __________________________________________
Principal
Date: ________________________________
Please print name: ______________________________________
All applications are subject to review and approval by DENTAQUEST.
All information contained in a credentialing file will be held in strict confidence, and available for review by
only duly authorized employees of DentaQuest Dental USA, Inc., the Plan, and/or third party review
organizations (i.e. NCQA, etc.). Practitioner has the right to obtain a copy of their credentialing file, by
submitting a written, signed request to the Supervisor of Credentialing at the corporate headquarters for. Any
corrections, additions, or clarifications to these files must be submitted in writing to the Supervisor of
Credentialing within 30 days of the original submission. This information will be added to the provider
application and considered in the credentialing decision. The practitioner has the right, upon request, to be
informed of the status of their credentialing or recredentialing application via phone, fax, or mail. If the
Credentialing Committee recommends the acceptance of an application with restrictions, denial of an
application, or discipline or termination of a practitioner, written notification will be issued within 30 days of
that decision. The practitioner then has 30 days from the date of the notice to submit a written appeal of that
decision. Appeals should be addressed to the Credentialing Committee, sent to DentaQuest’s corporate address.
In the event that a dentist’s application for participation is rejected or limited for reasons pertaining to the applicant’s professional conduct or competence, DentaQuest
is required to submit a report to the Plan. The Plan will submit a report to the National Practitioner Data Bank and the state licensing board as required by law.
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Disclosure of Ownership and Control Interest Statement
The federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a
provider agreement to disclose to the U.S. Department of Health and Human Services, the State Medicaid Agency, and to managed
care organizations that contract with the State Medicaid Agency: 1) the identity of all owners with a control interest of 5% percent or
greater, 2) certain business transactions as described in 42 CFR 455.105 and 3) the identity of any excluded individual or entity with
an ownership or control interest in the provider, the provider group, or disclosing entity or who is an agent or managing employee of
the provider group or entity. Please attach a separate sheet if necessary.
Practice Information (REQUIRED for all provider applications)
Check one that most closely describes you:
Individual
Name of Individual, Group Practice or Disclosing Entity:
Group Practice
Disclosing Entity
DBA Name:
Address:
Federal Tax Identification Number:
Are you _______________________ a 5% or greater owner in the entity associated with the Social
Print Name
Security number or Tax Identification Number (s) refere
If yes, complete sections I through VI and a signature and date are required. If No, a signature and date is all that is required.
Section I
List the name, title, address, date of birth (DOB) and Social Security Number (SSN) for each individual having an ownership or
control interest of 5 percent or greater in this provider entity.
List the name, Tax Identification Number (TIN) and business address of each organization, corporation or entity having an ownership
or control interest of 5 percent or greater. Please attach a separate sheet if necessary. (42 CFR 455.104)
Name of individual or entity
DOB
Address
SSN (if listing an individual)
TIN (if listing an entity)
Section II
Are any of the individuals listed above related to each other?
Yes
No
If yes, list the individuals named above who are related to each other (spouse, sibling, parent, child). (42 CFR 455.104)
Names
Relationship
Section III
Are there any subcontractors that the Disclosing Entity has direct or indirect ownership of 5% percent or more?
Yes
No
If yes, list the name and address of each person with an ownership or controlling interest in any subcontractor used in which the
disclosing entity has direct or indirect ownership of 5% percent or more. (42 CFR 455.104)
Name of individual or entity
08012013
DOB
Address
SSN (if listing an individual)
TIN (if listing an entity)
Page 9
Section IV
Has any person who has an ownership or control interest in the provider, or is an agent or managing
employee of the provider ever been convicted of a crime related to that person’s involvement in any
program under Medicaid, Medicare or Title XX program?
Yes
No (verify through HHS-OIG
Web site)
If yes, please list those persons below. (42 CFR 455.106)
Name/Title
DOB
Address
SSN
Section V
Business Transactions: Has the disclosing entity had any financial transaction with any subcontractors
totaling more than $25,000 or any significant business transactions with any subcontractors?
Yes
No
If yes, list the ownership of any subcontractor with whom this provider has had business transactions
totaling more than $25,000 during the previous twelve 12-month period; and any significant business
transactions between this provider and any wholly owned supplier, or between the provider and any
subcontractor, during the past five-year period. (42 CFR 455.105). Attach a separate sheet if necessary.
Name
Address
Transaction Amount
Supplier/Subcontractor
Section VI
Have you identified your status (under Practice Information1) as a Disclosing Entity?
Yes
No
If yes, for Disclosing Entities, list each member of the Board of Directors or Governing Board, including
the name, date of birth (DOB), Address, Social Security Number (SSN) and percent of interest.
%
Name/Title
DOB
Address
SSN
Interest
I certify that the information provided herein is true and accurate. Additions or revisions to the information
above will be submitted immediately upon revision. Additionally, I understand that misleading, inaccurate or
incomplete data may result in a denial of participation.
Signature
Title (or indicate if authorized Agent
Name (please print)
Date
08012013
Page 10