What is Dental credentialing?
Dental credentialing is a process of assessing, reassessing and validating the qualifications and practice history of a dental provider. The credentialing process is designed to evaluate the qualifications of dentists who provide care to our members. The credentialing process is conducted prior to participation in one of our networks. We recredential dentists based on timeframes established by state, regulatory and any applicable organizations. State, regulatory and any applicable organizations include state and federal-sponsored committees and accrediting bodies. You should be aware that the credentialing process is not a guarantee of any level of quality or service received from participating dentists. Participating dentists are independent practitioners in private or group practice and are neither agents nor employees of the health plan.

Why is credentialing important to members?
Credentialing is a key component of maintaining members' access to quality health care. Our commitment to credentialing involves an end-to-end process, starting with dentist recruitment and continuing through peer review. The credentialing process is designed so that dentists meet the requirements necessary to be a participating provider.

What does the credentialing process involve?
Credentialing includes:

• Data Gathering: The process of securing a complete application with demographic information and professional credentials.
• Business Criteria: Verifying provider falls within our business criteria for network participation.
• Primary Source Verification: Primary source verification is the process of authenticating information given by dentists who desire participation with Aetna. Aetna has established a Core Dental Credentialing department that is responsible for validating this information by direct interaction with sources such as the National Practitioner Data Bank (NPDB) and the individual State Dental Boards, via secure Internet and digital technologies.

• State licensing boards - validating the dentists' license to practice is active/unencumbered and confirming whether there are any sanctions against the license.
• National Technical Information Service (NTIS) - validating the practitioner's license to prescribe drugs. Certificates reviewed are the Drug Enforcement Agency (DEA) or Controlled Drug Substance Registration (CDS).
• General Anesthesia permit (if applicable) - validating the practitioner's permit to administer anesthesia.
• Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM).
• Malpractice insurance - confirming active coverage.
• Malpractice history - reviewing claims history.
• NPDB Query (National Practitioner Data Bank).
• Determining whether any disciplinary actions have been taken.

State and regulatory organizations mandate that health care companies query certain data banks to obtain information about a dentist's professional competency and conduct in practicing dentistry. We query the NPDB, which includes information secured from state dental licensing boards, to obtain information about sanctions and malpractice payments.

• Enhanced Data Gathering: involves research and collection of additional information concerning such issues as malpractice claims history, criminal convictions, sexual misconduct allegations/investigations, child abuse allegations/investigations, health issues and substance abuse.
• Ongoing Credentialing: involves ongoing monitoring of loss of license and other license sanctions by state licensing boards. This process can include updating DEA/CDS registration and credentials.
• Peer Review Decision: The Dental Credentialing and Provider Performance Committee (CPPC) is comprised of internal/external dentists. We conduct peer review of new practitioners, as well as recredentialing and performance review of existing, participating practitioners. The peer review process involves a review of the credentials verification, data gathering and enhanced data gathering information, as well as updated credentials information.

• We maintains a Customer Service unit to meet the specific needs of dental providers.
• Our distinction is that we have a centralized primary source verification process, and we credential participating dental providers through a consistent process, regardless of product.
• We maintains solid customer relationships due to the accuracy and timeliness of our credentialing processes.