CONTENTS

Dentegra Participating Provider Agreement Taxpayer Identification Number (TIN) Request Form Confidential Credentialing Information Form Office Information for Online Dentist Directory

Complete and sign the agreement on page 7 and all forms on pages 8-14. Please make a copy of this booklet for your records and return the entire original booklet to: Dentegra Insurance Company ATTN: Contracting and Administration 100 First Street M/S 5J San Francisco, CA 94105

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DENTEGRA PARTICIPATING PROVIDER AGREEMENT This agreement (Agreement) is entered into by and between the undersigned dentist, dental partnership, professional dental corporation, dental clinic, or dental care provider (Provider) and Dentegra Insurance Company1 (hereinafter, Dentegra). This Agreement shall become effective upon Dentegras initial written notice to Provider as set forth in Section I.2, below. RECITALS A. Dentegra issues or will issue various contracts to purchasers of dental care insurance or dental network access programs (Programs) for designated eligible enrollees (Enrollees). Such Programs arrange for certain dental services (Program Services) to be performed by dental care providers contracted with Dentegra (Participating Providers). Program Services include dental care services for which the Program is obligated to pay pursuant to an Enrollees Program contract, or for which the Program would be obligated to pay pursuant to an enrollees Program contract but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments. Provider desires to be a Participating Provider in such Programs and therefore agrees to the terms and conditions of participation as stated in this Agreement. I. 1.0 SELECTION AND PARTICIPATION Eligibility. To participate in the Programs, Provider must submit all required credentialing documents for each and every licensed dentist (including Provider) whom Provider intends to render dental services to Enrollees on Providers behalf (Rendering Professionals) and receive approval from Dentegra for each such Rendering Professional who meets Program credentialing criteria as determined by Dentegra. Such criteria include, but are not limited to: (a) Licensure. Provider warrants and represents that each Rendering Professional is now and shall continue to be the holder of a currently valid, unrestricted license to practice dentistry issued by an appropriate state agency, and that no Rendering Professionals license has been suspended, revoked or terminated or subject to terms of probation or other restriction within the past five (5) years. Provider also warrants and represents that each Rendering Professional has not been excluded from participating in any government-sponsored programs. Facilities and Equipment. With respect to each and every facility where Enrollees shall receive treatment, Provider shall ensure that such facilities are of adequate capacity and are clean, safe and readily accessible to Enrollees. All equipment used in such facilities shall be licensed and regularly checked as required by state and federal law to ensure that it meets health and safety standards, is environmentally safe and technically accurate. Insurance. Provider shall secure and maintain from insurance companies acceptable to Dentegra and approved to conduct business in the state where Provider is located, professional liability insurance and such other insurance as required by reasonably sound business judgment to protect Provider and each Rendering Professional (Insureds) and the Insureds partners, shareholders, directors, officers, members, employees and agents against losses and liabilities attributable to their acts or omissions in the performance of this Agreement. Such insurance shall have limits of coverage considered reasonably adequate by Dentegra for the risk insured against. Provider shall give Dentegra written notice within ten (10) days of cancellation or other termination of such policy.

B.

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(b)

(c)

1.1

Selection. Dentegra may, at its sole discretion, select Provider for participation, based upon Dentegras determination of Providers eligibility and need for Providers services. Dentegra may also, at its sole discretion, select or deselect individual Rendering Professionals based upon Dentegras quality management program, as described in Section V of this Agreement. Notification of Selection. Dentegra shall notify Provider in writing of Providers selection as a Participating Provider and when any Rendering Professional has been approved to treat Enrollees.

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Copyright 2012 by Dentegra Insurance Company. All rights reserved.

Dentegra Participating Provider Agreement II. 2.0 2.1 REQUIRED ADMINISTRATIVE PRACTICES, DISCLOSURES AND LEGAL COMPLIANCE

Dental Services. Provider agrees to provide Program Services for any Dentegra Program to eligible Enrollees in accordance with the terms, benefits, limitations and/or exclusions for the eligible Enrollees Program. Availability. Dental services are to be available during Providers regular business hours. Emergency Services shall be available twenty-four (24) hours per day, seven (7) days per week, including vacations and holidays. Provider may not impose any limitations on the acceptance or treatment of Enrollees not imposed on other patients. Locations. Provider shall submit information as required by Dentegra to accurately maintain its records for each office where Enrollees will receive dental services from Provider. This includes, but is not limited to the name and Tax Identification Number, as registered with the U.S. Internal Revenue Service to be used by Dentegra to issue payment for services, any business entity name, new or deleted office locations, the attributes associated with each office (e.g., hours open, languages spoken), etc. Office locations will not be activated until at least one dentist at the location, in the appropriate specialty, is approved by Dentegra as a Rendering Professional per Section 1.0. Eligibility Verification. Provider shall verify an Enrollees eligibility to receive Program Services at or before each visit in accordance with procedures established by Dentegra. Failure to verify eligibility may result in forfeiture of payment, including applicable Enrollee payments. Enrollee Grievance Procedures. Provider agrees to cooperate with Dentegra in identifying, investigating and resolving Enrollee grievances pursuant to applicable review procedures as described on our website or in written correspondence connected with specific grievances, and in accordance with state and federal regulatory guidelines as applicable. Provider agrees to comply with all final complaint and grievance determinations by Dentegra. Standard of Care. This Agreement shall not affect the provider/patient relationship between Provider and Enrollees. Provider shall render all services in accordance with generally accepted dental practice and standards prevailing in the professional community at the time of treatment. It is Providers responsibility to disclose various treatment options and the estimated costs associated with each option, regardless of whether or not they are Program Services under the Enrollees Program, and to secure the written consent of the Enrollee. Rendering Professionals. Provider shall timely identify Rendering Professionals to Dentegra throughout the term of this Agreement. Provider shall not permit any Rendering Professional to provide services to eligible Enrollees on Providers behalf unless such Rendering Professional has been approved by Dentegra as a Participating Provider. Provider shall ensure that each Rendering Professional complies with the terms and conditions of this Agreement. Required Disclosures. Provider agrees to notify Dentegra immediately in writing upon the occurrence or discovery of any of the following: (a) (b) (c) (d) (e) (f) (g) The license to practice dentistry of Provider or any Rendering Professional expires and/or is not renewed, is suspended, revoked, terminated or subject to terms of probation or other restriction; Provider or any Rendering Professional becomes the subject of any disciplinary proceeding or action before a state or federal agency; Provider or any Rendering Professional ceases to participate, is suspended or loses eligibility to participate in any state or federally sponsored dental program; Provider or any Rendering Professional is accused or convicted of fraud or a felony; The cancellation, termination or expiration of insurance coverage required under this Agreement; A malpractice action is instituted, settled or decided against Provider or any Rendering Professional; Provider files a voluntary petition or an involuntary petition is filed against Provider seeking bankruptcy, reorganization, arrangement with creditors or other relief under the bankruptcy laws of the United States or any other laws governing insolvency or debtor relief; An act of nature or any event beyond Providers reasonable control occurs which substantially interrupts or interferes with all or a portion of Providers practice or which has a material adverse effect on Providers ability to perform hereunder; A material change in the membership, ownership, and/or officers of Providers dental practice/corporation; or Any other situation arises which could reasonably be expected to affect Providers ability to carry out the obligations of this Agreement.
Copyright 2012 by Dentegra Insurance Company. All rights reserved.

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2.7

(h)

(i) (j)

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Dentegra Participating Provider Agreement To the extent reasonably appropriate and subject to any applicable state or federal fair hearing requirements, Provider shall immediately restrict, suspend or terminate a Rendering Professional from providing services to Enrollees upon the occurrence of any of the events referenced in Section 2.7. If Provider fails to act as required by this paragraph with respect to a Rendering Professional, Dentegra shall have the right to immediately prohibit the Rendering Professional from continuing to provide services to Enrollees. 2.8 Legal Compliance. Provider and Rendering Professionals shall: (a) (b) Treat Enrollees with the same quality and provide access to care consistent with the balance of Providers practice and not differentiate or discriminate against any Enrollee on the basis of source of payment; and Not unlawfully differentiate or discriminate against an Enrollee, employee or applicant for employment on the basis of race, religion, color, national origin, ancestry, place of residence, physical handicap, medical condition, marital status, sexual orientation, age or sex; and Comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Public Law 103-227 (US. Pro-Children Act of 1994 [20 USC 6081, et. seq.] and Section 1352 of Title 31), United States Code regarding prohibitions against using federal funds for lobbying; and Not employ or contract with, directly or indirectly, entities or individuals excluded from participation in Medicare or Medicaid under sections 1128 or 1128A of the Social Security Act, for the provision of dental services, utilization review, medical social work or administrative services; and Not condition treatment or otherwise discriminate on the basis of whether an Enrollee has executed an advance directive (as advance directive is defined under federal law). Comply with all applicable federal, state and local laws and regulations relating to administrative simplification, security, and privacy of individually identifiable Enrollee information, including but not limited to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(c)

(d)

(e) (f)

2.9
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Confidentiality of Dentegra Information. Provider and Rendering Professionals shall keep confidential and take necessary precautions to prevent the unauthorized disclosure of Dentegras confidential and proprietary information, including without limitation its financial arrangements with Participating Providers and any other information compiled or created by Dentegra and identified in writing as confidential and proprietary. Upon the termination or expiration of this Agreement, Provider shall return to Dentegra all confidential and proprietary information in the possession of Provider or any Rendering Professional. III. PROGRAM ADMINISTRATION Administration. Dentegra shall perform or contract for those services necessary to the administration of the Programs. Eligibility/Authorizations. Dentegra shall confirm the Program eligibility of Enrollees and the benefits under the Enrollees Program through the Dentegra website and automated telephone services. Processing Policies and Procedures. Dentegra shall make information describing Dentegras general policies and procedures and the policies and procedures of the Programs available to Provider and Rendering Professionals through its website and upon request Benefit Determinations. Dentegra shall be solely responsible for interpreting the terms of and making final benefit determinations under each Program with respect to Program Services and/or Enrollee payments. Rationale For Rejection of Claim. Dentegra shall, where required, disclose the rationale used in rejecting or denying a claim submitted by Provider. Dentegra shall pay Providers claims under the Programs in accordance with applicable state or federal prompt payment laws. IV. COMPENSATION Fees. Dentegra shall establish the fees payable to Provider as set forth in the Confidential Schedule of Contracted Fees, applicable to the Rendering Professionals specialty and region, which is in effect at the time Program Service is provided to an Enrollee. Dentegra shall pay Provider the portion of such fees that are not payable by the Enrollee based on the Enrollees Program. Such Confidential Schedule(s) of Contracted Fees are incorporated into this Agreement by this reference at the time they are issued to Provider in accordance with Section 8.0 of this Agreement. Any Confidential Schedule of Contracted Fees should not be disclosed by the Provider to a third party without the express permission of Dentegra. Provider agrees to accept no more than these fees as the total fee chargeable for Program Services.
Copyright 2012 by Dentegra Insurance Company. All rights reserved.

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3.3 3.4

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Dentegra Participating Provider Agreement 4.1 Claim Submission Requirements. For those Programs where Dentegra is responsible for paying any portion of Providers fees, Provider agrees to submit claims and provide Dentegra with claim data according to the policies and procedures set forth on the Dentegra website and consistent with requests in any written communications between Dentegra and the Provider. Provider further agrees to follow any applicable state and federal laws with respect to claim submission requirements or data elements associated with such transactions. This includes, but is not limited to, the guidelines found in the Health Insurance Portability and Accountability Act (HIPAA). Provider also agrees, upon request, to provide any other information that will enable Dentegra to meet federal, state and local reporting requirements. Provider further agrees to: (a) (b) (c) (d) Submit complete and accurate claims for all services provided to eligible Enrollees, whether Program Services or not; Include the fee regularly charged by Provider for such services; Use claim forms or formats acceptable to Dentegra; Submit claims within twelve (12) months after the date services were performed. Should any amount be denied by Dentegra for late submission, Provider agrees not to charge the Enrollee any balance that would have been paid by Dentegra if the claim had been submitted on a timely basis.

4.2

Enrollee Payments. Provider shall bill and collect any deductible, copayment and/or coinsurance from the Enrollee in the amounts determined by Dentegra to be applicable based on the Enrollees Program. Provider shall also bill and collect no more than the amounts set forth in the Confidential Schedule of Contracted Fees for those Enrollees in network access programs (please refer to paragraph 4.5 for obligations associated with optional treatment and non-Program dental services). Provider shall not waive, reduce or rebate any amount determined by Dentegra to be payable by an Enrollee. Prohibition Against Certain Billings and Collections Provider agrees to accept fees described in Paragraph 4.0 plus the Enrollee payments, pursuant to Paragraph 4.2, as payment in full for Program Services and not to seek any surcharge or other additional payment, regardless of whether or not payment is received from Dentegra. Whenever Dentegra receives notice of a surcharge, it shall take appropriate action. Neither Enrollees nor a Programs sponsoring entity shall be liable to Provider or any Rendering Professional for any sums owed to Provider by Dentegra. The foregoing shall not preclude Provider from billing and collecting authorized Enrollee payments pursuant to Paragraph 4.2 or third party collections in accordance with Paragraph 4.4. Third Party Payments. Provider shall cooperate with Dentegra in the proper collection of third party payments including coordination with other coverage, workers compensation, third party liens and other third party liability. Provider agrees to disclose any other insurance for which the Enrollee is also eligible on any claims submitted to Dentegra. Furthermore, if Dentegra is secondary, the Provider agrees to provide the explanation of benefits provided by the carrier that adjudicated the claim as the primary payor. Optional Treatment and Non-Program Dental Services. Unless a financial responsibility/optional treatment form has been executed between Provider and the Enrollee or the Enrollees legal representative, Provider shall not bill or collect from an Enrollee any charges in connection with a dental service even though that service is: (i) not a Program Service; (ii) not listed on the Confidential Schedule of Contracted Fees; or (iii) an optional form of treatment that is more expensive treatment than is customarily provided. Total reimbursement for any Program service performed shall not exceed (i) the amount listed on the Confidential Schedule of Contracted Fees; or (ii) for a service not listed on the Confidential Schedule of Contracted Fees, the fee that is accepted by Dentegra. Deductions and Refunds. Dentegra shall have the right to deduct and set off from amounts due to Provider any amounts owed by Provider to Dentegra or to Enrollees as a result of Providers failure to fulfill any business or patient obligation under this Agreement or Dentegras policies and procedures. Enrollees shall not be liable to Provider or any Rendering Professional for any such amount deducted or set off by Dentegra (or refunded by Provider) and Provider agrees not to attempt to collect any set off amount from Enrollees or maintain any action at law against Enrollees to collect such amounts. Non-Reimbursable Service Claims Submission. The submission of a claim for items or services which have not been provided as claimed is not reimbursable under any Program and is subject to applicable provisions of state and federal criminal laws. V. QUALITY AND UTILIZATION REVIEW Dentegras Responsibilities. Dentegra may be required by law to conduct quality and utilization review activities that identify, evaluate and remedy problems relating to access, continuity and quality of care, utilization and the cost of services. Dentegra shall maintain standards, policies and procedures for credentialing and recredentialing, and quality and utilization review of Participating Providers, Rendering Professionals, other health care professionals, and facilities providing dental services to Enrollees.
Copyright 2012 by Dentegra Insurance Company. All rights reserved.

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4.4

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4.7

5.0

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Dentegra Participating Provider Agreement As part of its review activities, Dentegra may also use or disclose Providers Tax Identification Number (TIN), National Provider Identifier (NPI) or other attributes to conduct analysis of accessibility, continuity and quality of care or to perform other dental benefit administration activities. 5.1 Providers Responsibilities. Provider and Rendering Professionals shall cooperate and comply with Dentegra, and designated representatives of organizations engaged by Dentegra, in connection with its quality and utilization review activities, including but not limited to credentialing and recredentialing, patient record reviews, and facility audits. Language Assistance Capabilities. Provider shall contact Dentegra if an Enrollee requests or evidently requires interpretation services in any language, which services will immediately be arranged by Dentegra at no cost to the Enrollee or the Provider. VI. 6.0 RECORDS AND AVAILABILITY FOR INSPECTION Dental Records. Provider shall ensure that an accurate and complete patient (treatment and financial) record for each Enrollee is established and maintained in Providers facility. At a minimum, such records shall include personal and health information about the Enrollee, a description of all services rendered to the Enrollee, and charges made and payments received therefore, as dictated by generally accepted dental practice and standards. Access to Dental Records. Subject to compliance with applicable federal and state laws and professional standards regarding the confidentiality of patient records, Provider shall assist Dentegra in achieving continuity of care for Enrollees through the maximum sharing of patient records for services rendered to Enrollees. Providers obligations under this Paragraph shall include, without limitation: (a) (b) (c) 6.2 Providing Dentegra with copies of Enrollee patient records that are in the custody of Provider or any Rendering Professional; Allowing Dentegra authorized personnel, its designated representatives, accreditation and review organizations and government agencies access to such records on Providers premises during regular business hours; Upon reasonable request, providing copies of an Enrollees patient records to any other Participating Provider treating such Enrollee.

5.2

6.1

Inspection, Audit and Maintenance. Provider and each Rendering Professional shall maintain the confidentiality of all Enrollee identifiable information, patient records and treatment in accordance with state and federal law. Provider and each Rendering Professional shall maintain such records and provide such information to Dentegra, the United States Department of Health and Human Services, or any other appropriate governmental official having jurisdiction as may be necessary for compliance by Dentegra with state and federal law and the rules and regulations duly promulgated thereunder, for a period of at least ten (10) years. All facilities, offices, records, books and papers of Provider and each Rendering Professional pertaining to Enrollees shall be open to inspection by Dentegra, its designated representatives, accreditation and review organizations, and state and federal authorities having jurisdiction over the Program during normal business hours. Provider and each Rendering Professional shall comply with any requirements or directives issued by Dentegra, accreditation and review organizations and government agencies as a result of such evaluation, inspection or audit of Provider or a Rendering Professional. The provisions of this paragraph shall survive termination of this Agreement for the period of time required by state and federal law. VII. TERM AND TERMINATION Term. When executed by both parties, this Agreement shall commence upon the Providers selection date as notified by Dentegra, pursuant to Paragraph 1.2 of this Agreement, and shall continue in effect until terminated in accordance with the terms of this Agreement. Termination. Either Provider or Dentegra may terminate this Agreement on ninety (90) days written notice. Dentegra may immediately terminate this Agreement upon the occurrence of any of the events set forth in Paragraph 2.7 (a) through (e) (Required Disclosures) subject to any applicable limitations of state or federal law. If this Agreement is terminated by Dentegra, Provider may not seek to become a Participating Provider until Provider demonstrates to Dentegras satisfaction that the issues which resulted in the termination of the Agreement have been resolved. Furthermore, unless otherwise stated by Dentegra at the time of termination of the Agreement, Provider may not reapply for participation for a period of at least twelve months following the termination of this Agreement. Dentegra will provide a terminated Participating Provider an opportunity to appeal such termination, as required by applicable state or federal law or by Dentegra policies and procedures. Any such appeal process shall replace the dispute resolution procedures described in Section VIII of this Agreement.

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7.1

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Copyright 2012 by Dentegra Insurance Company. All rights reserved.

Dentegra Participating Provider Agreement 7.2 Continuing Obligations Upon Termination. In the event of notice of termination of this Agreement or a Program, Provider shall continue to schedule and honor existing appointments of Enrollees until the effective date of termination. As of the effective date of termination of this Agreement or a Program, the provisions of this Agreement shall be considered of no further force or effect whatsoever and each of the parties shall be relieved and discharged here from, except that: (a) Termination shall not affect any rights or obligations that have previously accrued or shall thereafter arise with respect to any occurrence prior to the effective date of termination and any such rights and obligations shall continue to be governed by the terms of this Agreement; Unless Dentegra makes other reasonable and medically appropriate provision for the performance of services, Provider shall complete all dental services begun (but not completed) prior to termination. Provider agrees to specifically notify all Enrollees that the Provider is no longer contracted to render services as a Participating Provider. VIII. 8.0 MISCELLANEOUS PROVISIONS

(b) (c)

Amendments. Provider agrees to be bound by any amendment to this Agreement or the policies and procedures as posted on the Dentegra website for contracted Providers, effective forty-five (45) days after notice of such amendment is sent to Participating Providers. If Provider does not wish to be bound by such amendment, Provider shall notify Dentegra of his/her intent to terminate this Agreement within the 45-day notice period. Provider shall comply with any amendment required by law until the effective date of termination. The foregoing notice requirements shall not apply to amendments agreed to by mutual written consent of the parties or to amendments required for compliance with applicable law and regulations. Governing Law. This Agreement shall be governed, construed and enforced in accordance with the laws of the state where the Provider is located and the United States of America, as amended, and the regulations adopted thereunder, including but not limited to those enforced by a state insurance regulatory agency. Any provisions required to be included in this Agreement by state or federal law or by regulatory agencies with jurisdiction over Dentegra shall bind Dentegra, Provider and each Rendering Professional whether or not expressly provided in this Agreement. Provider acknowledges that this Agreement may be subject to approval by such regulatory agencies and may be amended by Dentegra, as set forth in Paragraph 8.0, in order to comply with applicable law and regulations. Incorporation by Reference. All exhibits, addenda and attachments to this Agreement, including Dentegras policies and procedures referenced in Section 3.2, are an integral part of this Agreement and are incorporated in full herein by this reference as if they are set forth at length. Entire Agreement. This Agreement, contracted fee schedules, appendices, and amendments hereto, contain all the terms and conditions agreed upon by the parties regarding the subject matter of this Agreement and supersede all prior agreements, either oral or in writing, with respect to the subject matter hereof. Notwithstanding the foregoing, this Agreement is not intended to supersede separate agreements that may be entered into with Dentegra for participation in other provider networks. Independent Contractor Relationship. The relationship between Dentegra and Provider is that of independent contractors. Provider, Rendering Professionals, and their respective employees and agents are not nor shall they be construed to be employees or agents of Dentegra. Dentegra, its employees and agents are not nor shall they be construed to be members, partners, employees or agents of Provider. Indemnification. Dentegra and Provider shall each agree to defend, indemnify and hold harmless the other party and its directors, officers, employees, affiliates and agents against any claim, loss, damage, cost, expense or liability arising out of or related to the performance or nonperformance by the indemnifying party or their respective employees or agents under this Agreement. Assignment. This Agreement, being intended to secure the personal services of Provider, shall not be subcontracted, assigned, transferred or pledged in any way by Provider and shall not be subject to execution, attachment or similar process, except that Dentegra may assign this Agreement and its rights, interests and benefits hereunder to any Dentegra parent company, affiliate or related entity. Disputes. Except as otherwise provided in this Agreement, disputes between Dentegra and Provider arising out of this Agreement shall be first resolved through the provider dispute resolution procedure described on the Dentegra website. If the provider dispute resolution procedure described above does not resolve the dispute, such dispute shall be subject to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association (AAA), and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction. The
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8.1

8.2

8.3

8.4

8.5

8.6

8.7

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Copyright 2012 by Dentegra Insurance Company. All rights reserved.

Dentegra Participating Provider Agreement initiating party shall give written notice to each other party of its demand to arbitrate on a form provided by the AAA, which notice shall contain a statement setting forth the nature of the dispute, the amount involved, if any, and the remedy sought, and shall file at any regional office of the AAA three copies of the notice, together with the appropriate filing fee required by the AAA. Arbitration hearings shall be held in a regional AAA office unless otherwise agreed upon between Dentegra and Provider. Such obligations are not terminated upon termination of this Agreement by rescission or otherwise. Any demand for arbitration shall be submitted within twelve months from the date of the action that is the subject of the arbitration or peer review. 8.8 Notices. Any notice required under this Agreement to either party shall be sent to that partys address of record by United States mail (postage prepaid, return receipt requested) or by overnight delivery. Any notice sent by U.S. mail shall be deemed to have been served upon and received by the addressee seventy-two (72) hours after the notice has been deposited in the U.S. mail. Any notice sent by overnight delivery shall be deemed to have been served upon and received by the addressee the next business day. Either party may change the place to which notice is being sent by giving written notice to the other of any change of address. Signatures. The signatories hereto represent and warrant that they have read the Agreement, understand it and are authorized to execute it on behalf of their respective principals or co-owners.

8.9

IN WITNESS WHEREOF, each of the undersigned has individually executed (in the case of an individual provider) or has caused this Agreement to be executed by its duly authorized representative (in the case of a dental partnership, professional dental corporation, dental clinic, etc.) as of the date(s) written below. Dentegra Insurance Company or Dentegra Insurance Company of New England

Legal name of provider/business entity IRS Tax Identification Number (TIN) Authorized signature
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Daniel W. Croley, DMD Vice President, Network Development

Print name of person signing Title (if applicable) of person signing Date Practice Location* Doing Business As (DBA) name Address ( ) Telephone number City ( ) Fax number State ZIP

Office email address

Mailing Address (if different from practice location) Address ( ) Telephone number City ( ) Fax number State ZIP

Office email address

*If this agreement applies to more than one practice location, please attach a separate sheet with complete information for each of the additional practice locations. Please return this entire signed original agreement and the other Provider forms. Once the participation process is complete, you will receive written notice.

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Copyright 2012 by Dentegra Insurance Company. All rights reserved.

TAxPAYER IDENTIFICATION NUMBER (TIN) REQUEST FORM

We require the following information for contracting and IRS income reporting purposes. Please resubmit this form any time you change practices, enter a new partnership, are issued a new taxpayer identification number, etc. Please fill out form completely. 1) IRS Taxpayer Identification Number 2) Legal name of the person, partnership or business (Payee) in which the above TIN (item #1) was issued by the IRS. If this does not match the IRS records exactly, payments to you may be subject to penalties and backup withholding.* Purpose of TIN Request Form We are required to file an information return with the IRS and must obtain your correct TIN to report income paid to you. Furnishing your correct taxpayer information and making the appropriate certifications will prevent certain payments from being subject to backup withholding.* We use this form as a substitute for the IRS Form W-9 (Request for Taxpayer Identification Number and Certification). Please refer to Form W-9 and its instructions if you require additional information. *What is Backup Withholding? Businesses making certain payments to you are required to withhold and pay to the IRS 28% of such payments under certain conditions. This is called backup withholding. If you provide the correct TIN and name combination and make the appropriate certifications, your payments will not be subject to backup withholding. Payments you receive will be subject to backup withholding if: (1) You do not furnish your TIN to the requester, (2) The IRS notifies the requester that you furnished an incorrect TIN or name, or (3) You do not certify your TIN. See IRS Form W-9 regarding exemptions from backup withholding. ZIP ) Specific Instructions for Individuals and Sole Proprietors Individual payees must generally provide their SSN as their TIN and the name shown on their social security card on line 2. If you have changed your last name, for instance, due to marriage, without informing the Social Security Administration of the name change, please enter the name shown on your social security card on line 5 and your new name on line 2. Sole proprietors must furnish their individual name and SSN, which is preferred by the IRS, or employer identification number (EIN) as their TIN. Enter your name(s) as shown on your social security card and/or as it was used to apply for your EIN on Form SS-4. You may also enter your business name or doing business as name on line 3. Penalties Failure to Furnish TIN. If you fail to furnish your correct TIN, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil Penalty for False Information with Respect to Withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 criminal penalty. Criminal Penalty for Falsifying Information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to furnish your correct TIN to businesses that must file information returns with the IRS to report income paid to you. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to governmental agencies to carry out tax laws. The IRS may also disclose this information to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable payments to a payee who does not furnish a TIN to a payer. Certain penalties may also apply.
Copyright 2012 by Dentegra Insurance Company. All rights reserved. E Dentegra 3052 #70382 (rev. 9/12)

3) Business name, if different from above (Doing Business As name) 4) License number 5) Dentist name 6) Practice location City State Phone # (

7) Mailing address (if different from practice location)

City State Phone # ( ) Individual/Sole Proprietor Partnership ZIP

8) Type of business entity: Corporation Other (please specify)

Certification I certify under penalty of perjury that: The Tax Identification Number and Payee Name I have provided is correct; The Payee is not subject to backup withholding; and The Payee is a U.S. person (U.S. citizen or resident; partnership, corporation, company or association; or any non-foreign estate or trust). Cross out the second bullet if the Payee has been notified by the IRS that it is currently subject to backup withholding.
Signature Date

Please return this form to: Dentegra Insurance Company ATTN: Contracting and Adminstration 100 First Street, M/S 5-J San Francisco, CA 94105
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CONFIDENTIAL CREDENTIALING INFORMATION FORM

This form must be completed by the contracting dentist and each associate dentist treating enrollees. Your responses on this form will be used to determine whether you meet the eligibility criteria for participation in the network. Treating dentists must maintain eligibility throughout the term of their participation.

1. Provider Information
Last Name: Other name used: First Name: Middle Initial:

q DDS q DMD q Other

Date of Birth:
(DOB is Mandatory)

q NPI Number q Male q Female q Dentist Social Security #

q Indicate Type
(SS# is Mandatory here not Tax ID or NPI)

Dental School: Specialty School (if applicable):

Year Graduated: Year Graduated:

q General Dentist q Pedodontist

q Orthodontist q Endodontist q
Yes

q Oral Surgeon q Periodontist q No

If yes, indicate which Board

q Prosthodontist

Are you currently Board Certified?

List hospital for which you have privileges: (List any additional hospitals on back.) Name:
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Address:

Copies of the following documents are required - Copies must be clear, legible and current
Dental License #: DEA Certificate #: Prof. Liability Ins. Co. Liability Limits: (Each Claim) NPI#: Practice Name: Practice Address: City: Contact Person: Practice Phone Number: If applicable: Controlled Substance Certificate #: Do you contract with Medicaid and/or CHIP?
Form #PADCU-01 (Rev. 9-12)
#70430

State:

Exp. Date DEA Exp. Date:

Policy #: (Aggregate Claim) Policy Exp. Date:

(If assigned and not previously submitted)

State: E-mail Address: Practice Fax Number:

Zip:

TEXAS ONLY: Exp. Date: TPI# (if applicable)

Practice owner/managing dentist submit current copy of X-ray Certificate of Registration. Page 1 of 4

Yes

q No

Copyright 2012 by Dentegra Insurance Company. All rights reserved.

2. Dental Work History for the Past Five Years

You must list a complete work history for the past five years including dates. Please provide an explanation of any work gaps greater than six months during the past five (5) years.
1. 2. 3. 4. 5.

Date: Date: Date: Date: Date:

3. Provider Checklist
Please note, we must receive the following documents from you in order to process your application:

q q q q q q q

A complete copy of this form (Credentialing Information Form) for all dentists at the practice A copy of each dentists current state license A copy of each dentists DEA certificate A copy of the declaration page of each dentists malpractice insurance A copy of the diploma from an accredited post graduate training identifying the specialty for each specialist as applicable
Do not detach
Page 2 of 4

Specialty only: If trained outside the U.S. or Canada, alternate pathways credentialing process required A signed copy of the enclosed form (Release to Produce Additional Certificate of Insurance Coverage) for each dentist

Date Stamp

Contracting and Administration Department 100 First Street, M/S 5-J San Francisco, CA 94105 Fax 4155129482
Form #PADCU-01 (Rev. 9-12)
#70430

Copyright 2012 by Dentegra Insurance Company. All rights reserved.

10

TO EXPEDITE THE CREDENTIALING PROCESS, THIS PAGE MUST BE COMPLETED IN ITS ENTIRETY.

4. Professional Attestation and Questions

Dentist First Name (Please print) Dentist Date of Birth Middle Initial Dentist License Number Last Name State Issuing License

I. Credentialing History (Please answer questions 1 - 10 below. For any Yes answer, explain on a separate piece of paper.)
Yes No 1.

q q q q q q q q q q q q q q q q
Do not detach

Has your license to practice in any jurisdiction, whether past or still pending, been denied, restricted, limited, suspended, revoked, not renewed, placed under probation, subjected to disciplinary action, or otherwise sanctioned, limited or curtailed?

2. Has your professional liability insurance ever been denied, suspended, revoked, canceled, or not renewed? 3. Has your Federal and/or State DEA license or applicable drug license ever been denied, suspended, canceled or not renewed, or subjected to any disciplinary action? 4. Has your status as a provider ever been denied, suspended, canceled or sanctioned by any municipal, state, federal or any other governmental agency (e.g. Medicare, Medicaid or Denti-Cal) HMO, EPO, PPO or other prepaid health plan? 5. Are your privileges or memberships at any hospital, institution (Military service) and/or HMO currently under investigation or have they ever been denied, suspended, reduced or not renewed? 6. Have you ever been denied membership, or renewal of membership, or been subject to disciplinary proceedings for a medical, dental or ethical reason by any dental/professional organization? 7. Are you unable to perform any procedures within the scope of privileges and duties in your position as a health care provider, with or without reasonable accommodations required by the Americans With Disabilities Act, within accepted standards of professional performance and without posing a direct threat to patients? 8. Do you currently, or did you in the last five years, engage in the unlawful use of illegal drugs, including the improper use of prescription drugs? 9. Do you have any felony or misdemeanor charges pending against you or have you ever been convicted of a felony, or pleaded nolo contendere to a felony? 10. Have you been involved in ANY malpractice (or any other civil) claims/lawsuits, settlements or judgments within the last five years? If yes, please provide detailed information on a separate sheet of paper including: docket number of the case, location of the court, names of the parties, plaintiff(s) and defendant(s), dates of the incident(s), description of the incident(s), your involvement, current disposition, and the amount of the settlement(s).

q q q q

II. Compliance & Malpractice Insurance (Answer questions 11, 12 and 13. For any NO answer, explain on a separate sheet of paper.)
No Yes

q q q q

11. Do you follow Center for Disease Control Guidelines for Infection Control in Dental Health-Care Settings and observe all applicable laws and regulations related to the practice of dentistry including, but not limited to, those dealing with infection control and employee safety in the work place? 12. Do you have current professional malpractice insurance coverage and agree to maintain continuous, uninterrupted coverage while either a contracted dental provider for the Plan or an associate of a contracted dental provider? Please note that under the terms of participation that you further agree to notify the Plan immediately of any policy cancellation, lapse in coverage, reduction in coverage maximum(s) or claims made. 13. Is practice accepting new patients?

q q

I authorize the Plan to consult with professional liability carriers, and other persons or entities to obtain information concerning my professional qualifications including competence, ethics and other qualifications. I, the undersigned, hereby certify that the information requested by the Plan and provided herein, is truthful, correct and complete in all respects. I further understand that the intentional submission of false or misleading information or the withholding of relevant information is grounds for denying participation or termination as a participating dentist with the dental plan. The undersigned hereby agrees to notify the Plan immediately of any changes in the above information. Upon request, practitioners have the right to review the information in their credentialing file and to ask for correction of any error or omission believed to be significant. To be accepted, any such requests must be submitted in writing to the Provider Administration department within 365 days of the practitioners last submission of completed credentialing forms.
Dentist Signature (no signature stamps):
Form #PADCU-01 (Rev. 9-12)
#70430

Date:
Page 3 of 4

Copyright 2012 by Dentegra Insurance Company. All rights reserved.

11

Release to Produce Additional Certificate of Insurance Coverage

I hereby request that ____________________________________________, from which I purchase my liability insurance, is authorized to produce an additional certificate of insurance coverage for the Contracting and Administration Department, 100 First Street, M/S 5-J, San Francisco, CA 94105. This certificate can be mailed at each renewal until otherwise notified.

Doctor Signature

Date

Policy Number
Do not detach
Page 4 of 4

Print Name

Date

License Number

Contracting and Administration Department 100 First Street, M/S 5-J San Francisco, CA 94105 Fax 415-512-9482

Form #PADCU-01 (Rev. 9-12)

#70430

Copyright 2012 by Dentegra Insurance Company. All rights reserved.

12

OFFICE INFORMATION FOR ONLINE DENTIST DIRECTORY

1. Name of practice (doing business as): Street address: City: 2.

_________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

_________________________________________________

State:

__________________

ZIP:

__________________

Office phone: ____________________________

Last name

Dentist name:
First name Initial

License number: _________________________________________________ 3.

Male

Female

Dental school #1: __________________________________________________________________________________________ Graduation year: ____________________ Dental school #2: __________________________________________________________________________________________ Graduation year: ____________________

4.

Type of practice: Solo Clinic Community clinic Dental school Mobile clinic Other _________________________________________ Group Practice (Attach a list of all dentists that will be credentialed to treat Dentegra patients)

5.
Do not detach

Your practice's web site address: ______________________________________________________________________ Special services provided in your office (Please check all that apply): Accessible by public transit Saturday hours Early morning appointments (before 9 a.m.) Sunday hours Evening appointments (after 5 p.m.) Treats children Treats disabled adults Treats disabled children

6.

7.

Wheelchair accessibility Your office can be listed as accessible to persons who use wheelchairs if it meets certain functional accessibility guidelines. Please verify that your office meets each of these guidelines: A. Doorways and entrances to the building and office are at least 32" wide. B. Hallways are at least 36" wide, with sufficient room for a wheelchair to make necessary turns. C. There is enough room for a wheelchair user to travel from the waiting area to the treatment area. D. The restroom has an accessible doorway, at least 48" of clear floor space, and grab bars to allow transfer to/from a wheelchair. E. The building or office is accessible by more than stairs or a steep slope. F. If the building has parking facilities, there are parking spaces reserved for people with disabilities.
Note: Your office will be listed as wheelchair accessible only if it meets all of these accessibility guidelines.

Yes Yes Yes Yes Yes

No No No No No

Yes No

(Continued on next page)

#70430

E Dentegra 3053 #70383 (rev. 9/12) Copyright 2012 by Dentegra Insurance Company. All rights reserved.

13

8.

Language spoken other than English in this office: If you need additional pages, please copy this form and attach. Name: Language(s) spoken other than English:

Dentist Staff
Name: Language(s) spoken other than English:

Dentist Staff
Name: Language(s) spoken other than English:

Dentist Staff
Name: Language(s) spoken other than English:

Dentist Staff
Name: Language(s) spoken other than English:

Dentist Staff

Please provide your contact information should we need to clarify any statements or data before updating Dentegra Insurance Companys online dentist directory. Contact name: __________________________________ Telephone number: (_____)_______________________ Email: ________________________________________ Practice Manager: ________________________________ Telephone number: (_____)_________________________ Email: __________________________________________
Do not detach

Please return this form to: Dentegra Insurance Company ATTN: Contracting and Administration 100 First Street, M/S 5-J San Francisco, CA 94105

#70430

Copyright 2012 by Dentegra Insurance Company. All rights reserved.

14

Complete and sign the agreement on page 7 and all forms on pages 8-14. Please make a copy of this booklet for your records and return the entire original booklet to:
Do not detach

Dentegra Insurance Company ATTN: Contracting and Administration 100 First Street M/S 5J San Francisco, CA 94105

100 First Street San Francisco, CA 94105

E Dentegra Enrollment #70430 (rev. 9/12)