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Provider Application

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Add a Cooperative PPO partner to your insurance mix. Complete the form below to become directly contracted with a Carrier partner. Follow the steps below:

Step 1) Beginning July 1, 2021, the Dental Cooperative will be exclusively using CAQH as the platform for collecting and verifying Provider credentials as part of the Insurance Fee Maximization process. CAQH is FREE for Providers to create and manage their credentials, reduces repetitive paperwork, and keeps all the information in one place to share with Carriers. Click here to create a CAQH account. For those already using CAQH, please verify the Provider is current and attested before you submit an action below to ensure faster submission.

Step 2) Review the associated fee schedule posted in Member Services. If the fees are acceptable, continue to Step 3.

Step 3) Verify you are NOT already directly contracted with the Carrier. Phone numbers for verifying are provided in the form process.

Step 4) Use the form below to submit a Provider Application Request with the Dental Cooperative insurance partners. Application requests will be processed only if the following criteria are met:

  • Provider is a current paying Member of the Dental Cooperative.
  • Provider is not directly contracted with the Carrier. Instructions to verify a direct contract are provided in the form below after you choose your requested Carriers.
  • Beginning July 1, 2021, all Providers will be required to have an updated CAQH account and provide their CAQH Provider ID.
  • All information requested must be included and current. Missing or expired data will delay the submission process.
  • Applications are submitted on behalf of Cooperative members, but Carriers reserve the right to restrict and deny requests based on their own criteria.

If you are having trouble with the form or need help, please contact your local Area Director for assistance.

    INSURANCE FEE MAXIMIZATION

    Provider Application Request Form



    IMPORTANT UPDATE - Beginning July 1, 2021, the Dental Cooperative will be exclusively using CAQH as the platform for collecting and verifying Provider credentials as part of the Insurance Fee Maximization process. CAQH is FREE for Providers to create and manage their credentials, reduces repetitive paperwork, and keeps all the information in one place to share with Carriers. If you need help onboarding with CAQH, please contact your local Area Director or the CAQH customer service at 888.599.1771.

    Requests can be submitted for an individual Provider only, but you may select multiple Carriers per action. For those using CAQH, please verify the Provider is current and attested before you submit an action below to ensure faster submission. Request forms should not be submitted if the Provider's Dental License, Malpractice Insurance, or DEA Certificate is within 60 days of expiration, due to expiration during processing. If within 60 days, please submit this request after the new Dental License, Malpractice Insurance, or DEA Certificate has been received.

    Membership Info:

    *required
    Requests can only be submitted for current Dental Cooperative Member Providers.


    Requests can only be submitted for current Dental Cooperative members. Please contact your local Area Director to add your Provider to the Dental Cooperative before submitting a request. Click here to find your local Area Director:



    Practice Info:









    Provider Info:

    A Provider Application Request form must be submitted individually for each Provider.














    Carriers Requested:

    You may select multiple Carriers. The Practice State in the Practice Info section must be selected to view the corresponding Carriers.

    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumana
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumana
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumana
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumana
    CareingtonCignaConnectionDenteMaxPrincipalLevelHumana
    CareingtonCignaGuardianPrincipalSun LifeZelisLevelHumana



    Participation Info:

    Submit a Provider Application Request form only if the Provider is NOT directly contracted with the selected Carriers. Use the phone numbers below if you need to verify if a Provider is already directly contracted:



    Careington Provider Relations Team 1-800-441-0380 (option 8)


    Cigna Provider Relations Team 1-800-244-6224


    Connection Provider Relations Team 1-800-821-6136


    DenteMax Provider Relations Team 1-800-752-1547


    Guardian Provider Relations Team 1-800-890-4774


    Principal Provider Relations Team 1-800-638-1959


    Sun Life Provider Relations Team 1-800-434-2638


    Zelis Provider Relations Team 1-800-878-7896


    Level Provider Relations Team 1-855-400-5705


    Humana Customer Service 1-800-833-2223



    Include any necessary notes, comments, or instructions:






    To qualify for Insurance Fee Maximization through the Dental Cooperative, Providers must meet the following criteria:
    • Provider must be a current, paying member of the Dental Cooperative in good standing.
    • Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
    • Provider, must be included in the original Associate Agreement with the Practice. If not included, Provider must sign and submit an Add Member Provider form prior to IFM requests.
    • Provider who has terminated their Dental Cooperative membership will have access to fee schedule resources terminated.
    • The Dental Cooperative will inform Carriers of membership termination and Carriers will take appropriate action as their individual policies dictate, which may include but not limited to a downgrade of fee schedule, return to previous fee schedule prior to membership or upgrade, or change to a base fee schedule indicated by the Carrier.
    • Provider must sign and return Insurance Fee Maximization Provider Agreement prior to any IFM requests.
    • The Dental Cooperative acts within the SEC parameters of a Messenger Model. Carriers reserve the right to restrict and deny requests based on their own criteria.





    Once submitted, we will verify your membership and information. Once verified, you will receive an email with instructions for the next step. Just hold tight until you receive the email.

    Please confirm the form submits. You will get a "Success!" message at the bottom of this form if it submits correctly. IMPORTANT: IF YOU DO NOT RECEIVE A CONFIRMATION EMAIL THAT WE RECEIVED YOUR DATA WITHIN 5 BUSINESS DAYS, PLEASE CONTACT YOUR AREA DIRECTOR.

    Having issues submitting the online form? Please contact your local Area Director: