Notices

• Online Provider Office Portal: Our new portal is now available with new and enhanced features 
  **Click here to learn about the new portal benefits!**
  
  
• Directory Information Verification (DIV): Update your provider directory information via our online portal and stop calls to your office to validate
  
  
• Provider Compliance Training (required annually): Training and Attestation materials available
  
  

• ADA Claim Form
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider DIV FAQ's
• Specialty Care Referral Form
• CMS Appointment of Representative Form

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

• Justification of Need For Prosthodontics

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

• California Provider Reference Guide
• Consent for Non-Covered Treatment - English
• Employee Language Pre-Screening Tool Kit
• Language Assistance Program (LAP) Notice
• LDP Provider Credentialing Application
• Orientation Brochure
• Orientation Brochure - Health Net

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form
• DHCS 5300 Application Form
• DHCS 6216 Application Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Secure Use and Transmission of Electronic PHI

Reference Materials

• Enrollment FAQs
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

COVID-19 Resources & Updates

• COVID-19 Federal Provider Relief Fund Payment Portal
• Dental Board of California - Update on Impacts Related to COVID-19
• Guidance for Resuming Deferred and Preventive Dental Care

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Reference Materials

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• CMS Appointment of Representative Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Opioid Risk Tool

Reference Materials

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS - Outpaitent Authorization Form
• Electronic Fund Transfer (EFT) Form
• Specialty Care Referral Form - Florida
• Specialty Care Direct Referral Request (FL SHOP & Individual- Adult Only Form)
• Provider Complaint and Dispute Form (fillable)

Reference Materials

• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• FL SMMC Medicaid Orientation Brochure
• Handicapping Labio-Lingual Deviations (HLD) Index Score Sheet
• Medicaid Behavior Management Report
• Non-Covered Treatment - Medicaid
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Secure Use and Transmission of Electronic Protected Health Information Policy
• SIU PP - Reporting FWA Neglect Exploitation
• Enrollment FAQs
• POE FAQs
• POE User Guide
• SMMC Regional State Map

Provider Manuals

• FL SMMC Medicaid Provider Reference Guide
• National Provider Reference Guide
• Florida Healthy Kids Provider Reference Guide

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• GA SMMC Regional State Map
• Consent for Non Covered Treatment
• Informed Consent for Alternative Treatment

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

• Illinois Orthodontic Criteria Index Form
• Justification of Need For Prosthodontics



Please send completed contracting packages to:
LIBERTY Dental Plan
PO BOX 401086
Las Vegas, NV 89140

• Orthodontia Scoring Tool

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• TOC - Orthodontic Transition of Care and Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Justification of Need For Prosthodontics

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• Electronic Fund Transfer (EFT) Form
• Provider Compliance Training & Attestation
• Provider Complaint and Dispute Form (fillable)

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Michigan SMMC Regional State Map

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointmentof Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Justification of Need For Prosthodontics

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• OrthoCAD Submission Form
• MO Orthodontic Continuation of Care Submission Form
• Site Application
• Justification of Need For Prosthodontics

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Opioid Risk Tool
• Handicapping Labio-Lingual Deviation Index (HLD) Score Sheet
• Instructions for the HLD Index Measurements

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

• Consent for Non-Covered Treatment
• ECHO EFT-ERA Reference Guide
• Medicaid Services Manual Chapter 1000 Dental
• NV Medicaid Orientation Brochure
• NV Medicaid Provider FAQs
• NV Medicaid Provider Training
• NV Medicaid Provider Reference Guide

Administrative Forms

• ADA Caries Risk Assessment Forms (ages 0-6 and over 6)
• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• ECHO Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) Form
• Member Grievance & Appeals Form - Spanish
• Provider Grievance Form
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Member Grievance & Appeals Form - English
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Clinical Criteria Guidelines and Practice Parameters
• Opioid Risk Tool
• Secure Use and Transmission of Electronic Protected Health Information Policy

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• 21st Century Cures Act Application
• ADA Caries Risk Assessment Form
• American Academy of Pediatrics Oral Health Risk Assessment Tool
• Appeal Form - NJ Department of Banking Insurance
• Attestation of Completed Preventive and Restorative Dental Treatment
• Consent for Non Covered Treatment
• Criminal Background Check Attestation
• Informed Consent for Alternative Treatment
• Informed Consent for Dental Treatment
• New Jersey - Ownership Disclosure Form
• NJ FamilyCare Orthodontic Transition of Care Form
• NJ Orthodontic Evaluation HLD (NJ-Mod3) Index Form
• Orthodontic Informed Consent Form
• Provider Compliance Training & Attestation
• Provider Complaint and Dispute Form (fillable)
• Site Application
• Specialty Care Referral Form

Educational Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Amerigroup NJ DSNP Model of Care Training
• Useful Tools for a Compliant Medicaid Provider: A Presentation for Dental Providers

Reference Materials

• NJ FamilyCare Managed Care Contract
• NJ Periodicity Schedule (Dental Services for Children NJ FamilyCare)
• NJ FamilyCare Dental Benefits Grid
• ECHO Portal User Guide
• LIBERTY ECHO FAQ Guide
• Enrollment FAQs
• 2022 NJ FamilyCare Clinical Criteria Policy and Grid
• 2023 NJ FamilyCare Clinical Criteria Policy and Grid
• 2024 NJ FamilyCare Clinical Criteria Policy and Grid
• NJ State Newsletter- Orthodontic Updates- Volume 32 No 2- January 2022 File
• NJFC FQHC Quick Reference Billing Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Territory Map of NJ - Network Managers

Provider Manuals

• National Provider Reference Guide
• Aetna Better Health of New Jersey - NJ FamilyCare Provider Reference Guide
• NJ FamilyCare Provider Reference Guide - Wellpoint
• NJ FamilyCare Provider Reference Guide - Fidelis Care

Survey Forms

• Long Term Care-Skilled Nursing-Mobile Facility Survey
• New Jersey - Americans with Disabilities Act Provider Survey Form
• New Jersey - Division of Developmental Disabilities and Aged-Blind-Disabled Form
• Demographic Survey Form

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• AAP Oral Health Risk Assessment Tool
• ADA Attestation
• ADA Caries Risk Assessment Form
• ADA Claim Form
• CMS Appointment of Representative Form
• Consent for Non-Covered Treatment
• ECHO Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) Form
• Emergency Oral Surgery Specialty Care Attestation
• Handicapping Labio-Lingual Deviation (HLD) Index
• Justification of Need For Prosthodontics
• NYS Medicaid – Evaluation For Dental Implants Form
• NYS - Justification Replacement Prosthesis Form
• Medicaid Enrollment Form
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Site Application
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Dental Policy and Procedure Manual
• ECHO Portal User Guide
• ECHO FAQ Guide
• EMEDNY - Medicaid Dental Policy Resources
• Enrollment FAQs
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• POE FAQs
• POE User Guide
• Provider DIV FAQ's
• Secure Use and Transmission of Electronic Protected Health Information Policy

Provider Manuals

• Aetna Better Health of New York Provider Quick Reference Guide
• ArchCare PACE Provider Quick Reference Guide
• Empire BlueCross BlueShield HealthPlus Provider Reference Guide
• Highmark BlueCross BlueShield Provider Reference Guide
• Highmark BlueCross BlueShield Provider Quick Reference Guide
• Independent Health Association Provider Quick Reference Guide
• Kalos Health Plan Provider Quick Reference Guide
• National Provider Reference Guide
• NYS Medicaid Child CHP Provider Reference Guide
• Provider Reference Guide - NY Medicaid (MLTC) & Medicare
• RiverSpring Health Plans Provider Quick Reference Guide - NY Medicaid and MLTC
• VillageCareMAX Provider Quick Reference Guide - NY Medicaid (MLTC) & Medicare

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Caries Risk Assessment Forms (ages 0-6 and over 6)
• ADA Claim Form
• Consent for Non-Covered Treatment
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Member Grievance & Appeals Form - English
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelinesfor Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Secure Use and Transmission of Electronic Protected Health Information Policy

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Justification of Need For Prosthodontics
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Justification of Need For Prosthodontics
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• Opioid Risk Tool
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Consent for Non-Covered Treatment
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Justification of Need For Prosthodontics
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Specialty Care Referral Form

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Texas Contracting & Credentialing Documents - Complete Packet

• Texas Contracting Packet (all documents) – Medicare
• Texas Contracting Packet (all documents ) – Medicaid
• Texas Contracting Packet (all documents) – All Lines of Business

Texas Contracting & Credentialing - Individual Documents

• Facility Application
• Medicare Addendum
• Medicaid Addendum
• Provider Check List
• Provider Authorized Signatory Form
• Provider Compliance Attestation
• Texas Provider Agreement
• Texas State Mandated Credentialing Application
• W9

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Secure Use and Transmission of Electronic PHI
• SIU PP - Reporting FWA Neglect Exploitation

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's

Administrative Forms

• ADA Claim Form
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation

Reference Materials

• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Opioid Risk Tool
• Orientation Medicare Advantage email

Provider Manuals

• Enrollment FAQs
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• POE FAQs
• POE User Guide
• Provider DIV FAQ's