PPO Provider Verification

With the Affordable Healthcare Act, there is a growing trend for legislation requiring insurance companies be held accountable for accuracy in their directories listing in-network providers. Prior to deciding on a plan, enrollees can know, with confidence, which doctors are in-network and accepting new patients.

Your office may be receiving notices requesting current directory information–do not ignore these! It is critical that these forms are completed and returned in a timely manner. If you are enrolling with PPOs, some are sending a link asking you to activate your directory profile in order to be included on their website as a preferred provider.  At the end of this post, we have included links to all major PPOs’ websites.

 

What happened in California…and what could happen in your state soon.

Last year, California instituted Senate Bill No. 137, the most extreme regulation to date, and is what some insurance companies and networks are modeling their requirements after for all states. There are strict penalties for the insurance companies for even the slightest of mis-information. If the directory lists a dentist as a DDS, but is a DMD, the insurance company could be fined. The insurance company would also be responsible for reimbursing an enrollee/insured for any amount beyond what the enrollee/insured would have paid for in-network services, if the enrollee/insured reasonably relied on the provider directory, as specified.

 

What happens if you don’t respond to notices?

If the insurer is unable to verify the provider’s information, the insurer may remove the provider from the directory and delay claim payment, after providing at least 10 business days advance notice.

The California bill requires health insurers to:

  • Make their directory viewable online to the public under specific search options (effective July 2017).
  • Use a consistent method of network naming, product naming, or other classification method to ensure easy identification of which providers participate in which networks for which products.
  • Verify the provider’s information by contacting the provider in writing, electronically and by telephone. The plan must document the outcome and each attempt to verify the information every 6 months.
  • Include a contractual requirement that providers inform the plan within five business days if they are not accepting new patients, or if they were previously not accepting new patients but are now open to new patients.
  • Update weekly their online directories with the following information:
    • Practice location address;
    • Provider area of specialty;
    • Languages spoken (other than English) by provider and staff;
    • Whether a provider is accepting new patients (with no restrictions or limitations);
    • Providers who participate in which networks and for which products;
    • And remove providers that are no longer under contract with the plan.

For California Residents:

SB 137 also required the Department of Insurance and the Department of Managed Health Care create one standardized provider directory template for California insurers. Providers can validate or correct their directory information in several ways:

  1. Online Form: Provider Data Reporting and Validation Form
  2. Email: CAProvData@cahealthwellness.com
  3. Secure Provider Portal: Logging into Secure Provider Portal
  4. Phone: 1-877-658-0305
  5. Fax: 1-855-463-4107

 

How can you stay on top of constant PPO changes?

Unitas PPO Solutions specializes in PPO negotiations, management and participation optimization. We’ve helped thousands of dentists increase their PPO revenue, and untangle themselves from the frustrating PPO insurance web. Click here to schedule a free consultation with us today.

 

Major PPO Website Directory Links

Aetna  – http://www.aetna.com/dse/search?site_id=docfind&langpref=en&tabKey=tab1

  • Search name of office or doctor’s last name as well as office zip code and click search.
  • Click “Continue without choosing a plan”

AlwaysCare http://alwayscare.go2dental.com/member/dental_search/searchprov.cgi

  • Select network “The Plus Network/Dentemax/AlwaysCare”
  • You may search by name of doctor or office or by location

Ameritas http://ameritas-dental.prismisp.com/

  • Enter office zip code and select the distance as “Exact”
  • Select the network as “Classic (PPO)”
  • Enter the doctor’s last name or office name.

Assurant https://www.assurantemployeebenefits.com/wps/portal/ForMembers/FindADentist

  • Select network “Assurant Dental Network”
  • Search by location or dentist name

Careington https://www1.careington.com/index.aspx#provider-search

  • Select “Prospective Members”
  • Enter doctor’s last name and the office zip code

Cigna https://ifphcpdir.cigna.com/web/public/ifpproviders?

  • Select “Dentist”
  • Enter zip code.
  • Select plans – Dental Plans – Cigna Dental PPO
  • Enter doctor’s last name or office name.

Connection http://www.connectiondental.com/

  • Hover over “Patient Info” on the header bar and select “Find a Dentist”
  • Search by Name or Location

Dentemax http://www.dentemax.com/findadentist

  • Enter Zip code
  • Click the column “Name” to list doctors alphabetically

Diversified (NV only) http://dds.go2dental.com/member/dental_search/provsel.cgi

  • Select appropriate state
  • Search by doctor’s name or location

DNoA https://c4.go2dental.com/member/dental_search/proxinp.cgi?brand=ildn&product=ppo&plan_number=50&zip=&maxlimit=100&pagelimit=20&dconly=&dnoa_prov_id=&lang=&pdftype=&saved_G2D_pagenum=&searchtype=byprox&sorttype=bydist&user=

  • Search by name or location

FDH  – https://www.firstdentalhealth.com/

  • Select “For Members” (located at the top left) and select “Find A Dentist”
  • Click Continue
  • Select network “PPO”
  • Enter doctor’s last name and Zip Code

Guardian https://www.guardiananytime.com/fpapp/FPWeb/dentalSearch.process

  • Enter zip code
  • Select plan “PPO”

Humana https://www.humana.com

  • Scroll down and under “Find a doctor or pharmacy” select “Search”
  • Change the search type to “dental” and click Go
  • Select “PPO” and enter zip code
  • Select network “PPO/Traditional Preferred”
  • Search by name, specialty or all

Metlife https://metlocator.metlife.com/metlocator/execute/Search

  • Select network PDP if directly contracted or PDP Plus if in network through another PPO
  • Enter zip code and select “in my zip only”
  • Search just by zip code or add doctor’s name

Premier Access https://www.premierlife.com/

  • Under “Members” select “Find a Dentist”
  • Enter zip code
  • Select Plan – Under Commercial Plans – “Dental PPO (Preferred Provider Organization)

Premier Dental Group http://www.premier-dental.com/find_pg.aspx

  • Select “Premier Classic”
  • Search by specialty, zip code, city/state or name

Principal http://c3.go2dental.com/member/dental_search/provsel.cgi

  • Select “Continue”
  • Select your state and the plan “Principal Plan PPO”
  • Enter either the doctor’s last name OR the office zip code and select continue

Stratose/Zelis http://providernow.coalitionamerica.com/Disclaimer.aspx

  • Check the confirm box and select continue
  • Click “here” (you do not have a four-digit Stratose PIN)
  • Enter the office zip code and state
  • Select type “Dentistry”
  • Select specialty (or select Dentistry)
  • Enter doctor’s last name or click search

TDA (Total Dental Administrators) https://www.tdadental.com//providers/find_provider.php

  • Select plan network “PPO”
  • Enter zip code OR city/state
  • Select Distance “5 Miles”
  • Select specialty if applicable

UCCI (United Concordia) https://www.unitedconcordia.com/find-a-dentist/content/SearchCriteria.xhtml?timeout=true

  • Select specialty if applicable
  • Enter zip code
  • Click “Show Dentists in My Area”
  • Select “Dentist/Practice name on left side of page and enter info to narrow results

UHC (United Healthcare) https://www.uhc.com/find-a-physician111

  • Under “Additional Directories” select “Dentist”
  • Search by location, dentist name or practice name

 

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