DCS Dictionary: Dental Credentialing Terms

Moving through the complex dental billing process means you have a plethora of terms thrown your way — especially when you’re moving through the credentialing process.

There are so many abbreviations and acronyms to keep straight, it can be overwhelming. But this is crucial information that you need to know, so we’re simplifying it for you by presenting the most important terms in one place using clear language.

As a full-service revenue cycle management provider, one of the DCS specialties is automated credentialing and re-credentialing for dental professionals.

DCS Credentialing cuts costs and increases efficiency when enrolling providers throughout the US, with a digital dashboard for checking the status of your application from anywhere, at any time.

Now, with the collected expertise of the DCS Knowledge Network, we’re clearing up the confusion with our Credentialing Dictionary for these 6 terms

• NPI (National Provider Identifier)
• CAQH (Council for Affordable Quality Healthcare)
• Enrollment
• Re-credentialing
• Termination of contracts
• TIN change (Tax Identification Number change)

1. NPI (National Provider Identifier)

An NPI, or National Provider Identifier, is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

There are two types of NPIs:

• NPI Type 1: Identifies an individual healthcare provider, such as a doctor or dentist. In addition to being used for medical and dental claims processing, this type of NPI is used by pharmacies to identify the prescribing doctor. 
• NPI Type 2: Identifies an organization or billing entity, such as a dental clinic, practice, corporation, hospital, or dental school. It’s a common misunderstanding that a Type 2 is only necessary when the dental organization is incorporated — an organization may also be a partnership, sole proprietorship, or LLC. 

In dental credentialing, the NPI 2 is essential for billing and claims submission. It identifies the specific dental provider involved in the care, ensuring that claims are processed accurately and promptly. Misreporting NPI numbers can lead to claim denials or delays.

Read more: How do I correctly report NPI numbers on the dental claim form?

2. CAQH (Council for Affordable Quality Healthcare)

CAQH, or the Council for Affordable Quality Healthcare, is an online database that stores provider information, and is used by insurance companies for credentialing.

The CAQH streamlines the credentialing process by allowing providers to enter their information one time and in one location, to then be accessed by multiple insurers. This simplifies the process of updating, maintaining, and utilizing provider data, making credentialing more efficient.

3. Enrollment

Enrollment refers to a dental provider being officially recognized and registered with an insurance company to provide care to the patients covered by that insurance company.

Enrollment involves the insurer verifying the dental care provider's qualifications and that dental care provider agreeing to the insurer's terms. This exchange is a critical step in credentialing, as it paves the way for providers to be reimbursed for their services by the insurer.

Read more: Top 5 mistakes dentists make in the dental credentialing process

A significant detail: The number of insurance providers you enroll with can affect your fee schedule. For example, if you enroll with too many insurance companies at once, like an umbrella insurance company, you could end up enrolled with some smaller, obscure insurance companies that often impose lower fee schedules.

To avoid this problem:

1. Do your research to uncover the most common insurance providers in the area where your dental practice serves. Figure out which insurance providers most locals are using.
2. Enroll with just 4 or 5 of those providers, so you will be accessible to most people across the fewest providers.

4. Re-credentialing

Re-credentialing is the insurance companies’ periodic reevaluation of a dental care provider's credentials and qualifications to confirm that dental practitioners in their network remain professionally qualified, and to ensure ongoing compliance with insurance standards.

Re-credentialing typically occurs every few years and requires a submission of up-to-date documentation to confirm that your license is in good standing, you are qualified according to the insurer’s eligibility criteria, and that the insurance company has current information.

The good news is, insurance companies will typically mail a reminder when it’s your time to be re-credentialed. The not-as-good news is that it takes weeks for your submission to be fully processed. 

Consistent credentials are vital if you want to remain in-network with these insurance companies. If you don’t become re-credentialed by the insurance company’s provided deadline, your services will not be covered by that insurance. Your patients will have to find another dentist who is in-network with their insurance, or pay entirely out-of-pocket — and we doubt they’d be happy about either one.

Submit your re-credentialing documentation as soon as it’s requested to ensure smooth operations, happy patients, and continuous cash flow for your dental business.

5. Termination of contracts

Termination of contracts term refers to the formal ending of a dental care provider's agreement with an insurance company. Contract termination involves navigating the terms of the contract, and understanding the details and abiding by those terms are how you’ll ensure a smooth transition and an uninterrupted revenue flow. 

It’s helpful to have an expert who is skilled with insurance company contracts to advise you on when and how — or if — you should terminate your agreement.

Related: 3 ways dental credentialing issues can cost your practice

6. TIN change (Tax Identification Number change)

TIN change involves updating the Tax Identification Number, which is used for federal tax and insurance billing purposes. A TIN change is significant in credentialing, as it affects all revenue-based documentation for claims and patient billing, as well as federal tax tracking and reporting.

Prompt updating of TIN information is essential to avoid denied claims and tax filing issues. Part of our DCS Credentialing service includes updating your TIN everywhere it occurs when you set up a new practice.

Ensure swift and accurate dental credentialing: Access the DCS Knowledge Network

Well-managed credentialing is how you avoid costly billing mistakes that could also drive patients away. When you work with DCS, you gain access to over 100 experts through the DCS Knowledge Network, ensuring that your credentialing process is handled accurately and swiftly.

We've covered essential terms like: 

• NPI (National Provider Identifier)
• CAQH (Council for Affordable Quality Healthcare)
• Enrollment
• Re-credentialing
• Termination of contracts
• TIN change (Tax Identification Number change)

Understanding these terms and taking correct action to maintain your credentials are not just about compliance or convenience; they’re keys to ensuring the continued financial health of your dental business.

Partner with DCS and leverage our expertise for your professional success. 

Tap into our credentialing expertise: Book a call today.