The dental care sector faces challenges across multiple areas, including the delivery of quality treatment, customer acquisition & retention, billing, collections, credentialing, etc. The team needs to juggle multiple terms thrown at them.
The credentialing process has various terms and acronyms that the dental team needs to understand. The DCS dictionary can help to comprehend and make sense of the credentialing process. While understanding dental credentialing terms can be overwhelming, the team must have a thorough grasp of them.
A CAQH survey done a few years ago estimates that automating administrative transactions can help the dental industry save up to USD 3 billion. The survey also indicated that the electronic transaction volume increased by 15% in 2019. What’s noteworthy is that this represented 46% of transaction volume.
The global credentialing market for software across the healthcare market size in 2023 was pegged at a little over USD 807 and is expected to cross USD 1.4 billion in 2030.
Automated credentialing and re-credentialing for dental practitioners can save time and money for the practice. It helps to safeguard revenue by doing things effectively and on time. Moreover, once the team has access to all the vital information needed, it can carry out credentialing with ease and efficiency.
Mentioned below is a DCS glossary that helps in comprehending all the key terms in one place using clear language. The team can clear up any confusion about dental credentialing terms as follows:
The National Provider Identifier is an exclusive ten-digit identification number. It is issued to health care professionals in the USA. The number is provided by CMS (Centers for Medicare and Medicaid Services (CMS).
There are two types of NPIs as outlined below:
NPI Type 1 is about an individual healthcare professional. This could be a dental practitioner or a doctor. This number can be used for processing dental or medical claims. This number is used by pharmacies to associate prescriptions with the respective healthcare professional.
NPI Type 2 corresponds to dental practices, a healthcare entity, a hospital, or any such billing entity. It is a general perception that a Type 2 is only required for a dental organization that is incorporated. The entity can be registered as an LLC, sole proprietorship, or partnership.
From a dental credentialing perspective, the practice needs an NPI 2 number for billing and submission of claims. This helps to identify the specific dental provider associated with the delivery of treatment and care to the patient.
CAQH, or Council for Affordable Quality Healthcare, also works as a database that provides precise data records on nearly 5 million provider records and approximately 240 million members.
Insurance firms use it for extracting patient data. It is a repository of data on healthcare providers. Insurance organizations refer to the CAQH for credentialing dentists and doctors.
It helps to streamline the credentialing process by enabling healthcare providers to enter all necessary data in one location, and this can be accessed by any insurance organization. Hence, the process of updating, maintaining, and using data of healthcare providers for credentialing is made simple and efficient.
The purpose of enrollment refers to the official acceptance and registration of a dental provider with the insurance organization. This facilitates the passing of claims for patients who have coverage with the respective insurance company.
Besides the verification of qualifications of the dental practitioner, enrollment also insists on the acceptance of the terms of the insurance company by the dental practitioner. This is a vital step in dental credentialing, as it ensures that the insurance company reimburses the provider for treatment rendered.
When a dental care provider gets enrolled with too many insurance companies, it can affect the fee schedule. Enrollment with a large number of insurance companies simultaneously could result in the provider being enrolled with smaller, unrecognized insurance organizations that demand lower fee schedules.
The dental team can undertake a survey and identify common insurance providers in the vicinity of the practice and the prominent ones being used by patients in the area. The practice can enroll with five or six insurance companies, as this helps the practice to strike the best fee schedule with them while reaching out to the maximum number of patients.
Re-credentialing needs to be done as part of a periodic reevaluation of a dental practitioner’s qualifications and credentials by the insurance organization. This helps to ascertain that the dentists in the network are professionally qualified and are compliant with prevailing insurance standards.
The process needs to be done every two or three years. It needs a submission of the latest documentation that confirms the license of the dental practitioner is valid and relevant. This also proves that the dental practitioner has met the eligibility criteria of the insurance company.
Generally, an insurance company will send reminders when the time for re-credentialing is a few weeks away. Re-credentialing can take a few weeks, and hence, the dental team should not delay the process.
The practice needs to make sure that dental practitioners are always credentialed, as this helps to stay in-network with insurance firms. Missing a deadline for re-credentialing results in services not being covered by the insurance company. This can lead to patients switching to another practice that is in-network with their insurance.
Hence, re-credentialing done on time helps the practice to run smoothly while ensuring a steady stream of cash flow.
Termination of contracts is a term that refers to the formal closure of the relationship that the dental practice has with an insurance firm. Termination of the contract involves navigating the terms of the contract, comprehending the details and terms.
This is important as the dental team needs to ensure a smooth transition with another insurance firm and uninterrupted cash flows. The practice can use the services of an independent expert on insurance company contracts. The practice can get a sound opinion on how or when to terminate the contract.
A change in the Tax Identification Number involves updating the number that is needed for federal tax and insurance billing purposes. A change in the tax identification number is important from a credentialing perspective.
The change in TIN has an impact on revenue-based documentation for billing and claims. It also affects federal tax tracking and reporting. The dental team must ensure the speedy updating of TIN data. This can help to prevent tax filing issues as well as rejection of claims submitted by the team.
Dental credentialing is a crucial process for a dental practice. It helps to ensure patient satisfaction and prompt reimbursement of claims.
Understanding dental credentialing terms and processes helps to boost efficiency while helping the practice to stay profitable and compliant.
Capline Dental is a leading provider of end-to-end services to dental practices of all sizes in the USA and can be reached at info@caplinedentalservices.com
