Upgrade Request

Time to request a raise.

Dental Cooperative Members can request to upgrade to the associated Cooperative fee schedules with our partner carriers. Each carrier’s fee schedules are different, including carrier specific restrictions and terms. To achieve the upgrade associated with Cooperative Members, the form below must be submitted to the Dental Cooperative exclusively through the online form.

Step 1) Review the associated fee schedule posted in Member Services. If the fees are acceptable, continue to Step 2.

Step 2) Verify you are directly contracted with the Carrier prior to requesting an upgrade. If you are not directly contracted, please click here to complete the Provider Application Request. If you are directly contracted, continue to Step 3.

Step 3) Use the form below to submit an Upgrade request with the Dental Cooperative insurance partners. Upgrade requests will be processed only if the following criteria are met:

Provider is a current paying Member of the Dental Cooperative.
Provider is directly contracted with the Carrier. Instructions to verify a direct contract are provided in the form below after you choose your requested Carriers.
For first-time insurance requests through the Cooperative, an Initial Provider Data form must be submitted prior to the Upgrade Request. Click here to complete the Initial Provider Data form.
All information requested must be included and current. Missing or expired data will delay the submission process.
Most Carriers restrict upgrades within a specific time frame. Upgrades requests within the restricted time period will not be submitted. Review Member Services to check any restricted time frames for each Carrier.
An Upgrade Request is a request to be added to the Cooperative associated fee schedule. The Cooperative will do everything we can to help to achieve your upgrade, 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

Upgrade Request Form

An Upgrade Request must be submitted individually for each provider.

Membership Info:

Requests can only be submitted for current Dental Cooperative Member Providers.
PROVIDER IS A CURRENT MEMBER OF THE DENTAL COOPERATIVE*

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:

IS THIS A NEW ASSOCIATE TO YOUR PRACTICE?*

FOR THIS NEW ASSOCIATE, HAVE YOU ALREADY SUBMITTED AN "INITIAL PROVIDER DATA" FORM?*

New Providers are required to submit an Initial Provider Data form. Please click here to complete the Initial Provider Data form prior to your request.

Practice Info:

*required

PRACTICE NAME*

PRACTICE STATE*

COOPERATIVE ACCOUNT# (optional. Found on your Summary of Benefits.)

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

Carriers Requested:

An Upgrade Request must be submitted individually for each provider. You may select more than one Carrier request per Provider.
Select a Practice State in the Practice Info section to view the corresponding Carriers.

PLEASE SELECT THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR UPGRADE REQUEST TO:*

CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis

CareingtonCignaConnectionDenteMax

CareingtonCignaGuardianSun LifeZelis

Participation Info:

Providers are required to verify the following information with Carriers prior to submitting an Upgrade Request. Carrier phone numbers are provided for your convenience:

CAREINGTON
Careington Provider Relations Team 1-800-441-0380 (option 8)
CAREINGTON: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

CAREINGTON: PARTICIPATING PLANS
Careington Platinum PPOCareington Platinum POSCarePPOCarePOS500 Series

CAREINGTON: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

CIGNA
Cigna Provider Relations Team 1-800-244-6224
CIGNA: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

CIGNA: MOST RECENT EFFECTIVE DATE mm/dd/yyyy

CIGNA: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

CIGNA: PARTICIPATING PLANS

CONNECTION DENTAL(GEHA)
Connection Provider Relations Team 1-800-821-6136
CONNECTION: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

CONNECTION: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

DENTEMAX
DenteMax Provider Relations Team 1-800-752-1547
DENTEMAX: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

DENTEMAX: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

GUARDIAN
Guardian Provider Relations Team 1-800-890-4774
GUARDIAN: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

GUARDIAN: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

PRINCIPAL
Principal Provider Relations Team 1-800-638-1959
PRINCIPAL: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

PRINCIPAL: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

SUN LIFE(DHA)
Sun Life Provider Relations Team 1-800-434-2638
SUN LIFE: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

SUN LIFE: MOST RECENT EFFECTIVE DATE mm/dd/yyyy

SUN LIFE: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

ZELIS
Zelis Provider Relations Team 1-800-878-7896
ZELIS: CONTRACTED EFFECTIVE DATE mm/dd/yyyy

ZELIS: CURRENT FEE SCHEDULE NAME/CODE (may be found at bottom of printed fee schedule)

Provider Info:

An Upgrade Request form must be submitted individually for each provider.

FIRST NAME*

MIDDLE NAME

LAST NAME*

SPECIALTY*

PROVIDER EMAIL*

PROVIDER'S NPI#*

CAQH# (If provider uses CAQH.)

CAQH#* (Required in New Mexico.)

PROVIDER MALPRACTICE INSURANCE DECLARATION PAGE* (file types:gif|png|jpg|jpeg|pdf)

TOTAL NUMBER OF LOCATIONS PROVIDER PRACTICES*

PROVIDER W9 FOR EACH LOCATION* (1-10 Locations)(file types:gif|png|jpg|jpeg|pdf)
Click to Download W9

PROVIDER W9 FOR EACH LOCATION* (10-20 Locations)(file types:gif|png|jpg|jpeg|pdf)
Click to Download W9

Provider License Data:

Please provide the most current license information for the Provider listed above.

PROVIDER DENTAL LICENSE#*

DENTAL LICENSE STATE*

DENTAL LICENSE EXPIRATION DATE* mm/dd/yyyy

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.
• Provider, if not a current Member and/or not included in the original Associate Agreement with the Practice, must sign and submit an Add Member Provider form prior to IFM requests.
• Participating Practice must have signed and submitted an Associate Agreement 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. An Upgrade Request is a request to be added to the Cooperative associated fee schedule. The Cooperative will do everything we can to help to achieve your upgrade, but Carriers reserve the right to restrict and deny requests based on their own criteria.
• Most Carriers restrict upgrades within a specific time frame. Upgrades requests within the restricted time period will not be submitted.

I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed mm/dd/yyyy (required)

Signature of Authorized Agent* (Draw/sign below)

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, sometimes it takes a minute to go through. 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 US!

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