Medicare Advantage Network Contracting & Compliance
Delta Dental’s Medicare Advantage membership is growing, and your participation in this network is a great opportunity to increase the number of patients at your dental office. If your dental office is considering joining our Medicare Advantage network or is already participating in this network, you'll need to ensure compliance with the Centers for Medicaid and Medicare Services (CMS) requirements for Medicare Advantage providers. Use this page to connect with the resources you'll need to stay compliant.
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Medicare Advantage Changes for 2025
Moda Health Plan and Summit Health Medicare Advantage plans ending in 2025
Moda Health Plan, Inc. has made the difficult decision to discontinue individual Medicare Advantage medical plans. Beginning January 1, 2025, Moda will no longer be offering Medicare Advantage plans in the state of Oregon.
- This does not affect Providence Health or Devoted Health Medicare Advantage plans. These plans will continue in 2025.
- This does not affect current provider Medicare Advantage Supplemental Dental contract status. Your participation status will not change.
- This does not affect other Medicare Advantage Supplemental plans offered by other Delta Dental member companies.
Members will need to select a new Medicare Advantage Plan and may inquire which carriers you are contracted with. Please direct patients to our member support page for any questions on their 2024 benefits.
Transition to PPO Fee Schedule
Effective Jan. 1, 2025, Delta Dental of Oregon's Medicare Advantage reimbursement will follow the PPO fee schedule. This change aims to support our Medicare Advantage health plan partners while maintaining affordability for seniors.
Key Information for Providers
- Effective date: Jan. 1, 2025
- Fee schedule access: Contact Dental Professional Relations at dpror@deltadentalor.com
- Response deadline: Oct. 31, 2024
If you are a Premier-only provider, this change will not automatically enroll you in the Delta Dental PPO network. No action is needed to remain in-network with Medicare Advantage.
Providers wishing to end their Medicare Advantage contract should email a request form to orcontracting@deltadentalor.com or fax it to 503-243-3965 by Oct. 31, 2024. Requests received after this date will follow CMS guidelines, requiring a 60-day notice.
Out-of-Network Providers
Out-of-network providers can still see Medicare Advantage patients, but certain plans may require treatment from an in-network provider. Services provided by non-contracted providers could be fully out-of-pocket for the patient. Please check Benefit Tracker for patient eligibility.
Non-covered Services Waiver
The term non-covered service applies to any procedure that is not a part of the patient’s plan benefits. For example, if the patient wanted a dental implant, but implants are not covered under the plan, the member’s signed consent for the service would be needed. Please note that frequency or annual maximum denials do not constitute a non-covered service.
No specific financial waiver is required, however, DDOR has created one in case that’s helpful for your office. You do not need to submit these with your claims, they just need to be in the members file in case they are requested due to an appeal or other kind of review request.
Fraud, Waste & Abuse (FWA) Training
MA contracted providers and their employees must complete FWA Training annually and within 90 days of hire. This training will help dental office staff understand how to identify and report possible infractions.
View TrainingExclusion Screening
Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE)
OIG's LEIE provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other federal health care programs. You should check the list monthly to ensure that new hires and current employees are not on it.
General Services Administration (GSA) or System for Award Management (SAM) List
The GSA similarly maintains several exclusion lists, managed through the System for Award Management (SAM). You should routinely check SAM to ensure that excluded individuals and/or entities are not involved in provision of care or services on behalf of your office.
CMS Preclusion List
CMS maintains a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services, or Part D drugs furnished or prescribed to Medicare beneficiaries. You will receive an email and letter from CMS/Medicare Administrative Contractors in advance of your inclusion on the preclusion list. The email and letter will be sent to your Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing. The letter will contain the reason you are precluded, the effective date of your preclusion, and your applicable rights to appeal. Medicare Advantage plans are required to deny payment for a health care item or service furnished by an individual or entity on the preclusion list. To learn more about the CMS Preclusion List, visit CMS.gov.Medicare Advantage Contracting and Resources
Medicare Advantage Provider Handbook
The Delta Dental Medicare Advantage Provider Handbook will serve as a useful source of information for you and your office staff.
Medicare Advantage Network Contract
Interested in joining the network? Simply complete the attached contract to become an in-network provider.
Annual Compliance Attestation
Delta Dental is required to monitor and ensure your organization operates in compliance with applicable laws and regulations required by CMS and your Participating Dentist Agreement. Each year, you are required to affirm your commitment to comply with each of the listed topics in the attestation that apply to your organization and the services you provide for Medicare Advantage business. For more information see the Attestation Appendix.
Offshore Subcontracting Attestation
CMS requires disclosure of Medicare Advantage providers’ offshore subcontractor activities. Contracted dental offices (also referred to as first-tier or downstream entities) that subcontract with any offshore entities to process or have access to patient protected health information (PHI) must complete this attestation within 10 calendar days from the date a contract is signed or immediately upon knowledge of this requirement.
DDOR Medicare Advantage Partnerships
Click the logos below for more information on plan details and benefit grids.
Frequently Asked Questions
How do I join the Delta Dental Medicare Advantage™ Network?
If you would like to join our Medicare Advantage network, please email your request to ORContracting@deltadentalor.com. A member of our Provider Relations team will reach out with next steps.
I no longer want to participate in the Medicare Advantage network. What do I do?
If you would like to terminate your Medicare Advantage contract, please email your request to ORContracting@deltadentalor.com. A member of our Provider Relations team will reach out with next steps. Please note that contract terminations require 60 days prior notice.
I’m opted-out with CMS, can I join the network?
Yes, due to changes in CMS’ guidelines around supplemental benefits, opted-out providers may now be paid for supplemental dental services and may also join our network.
By joining the DDOR Medicare Advantage network, will I be directly opting-in with CMS?
No, joining our network does not result in changes to your direct CMS status. You are also not required to directly opt-in or opt-out with CMS to join the network.
If I decide to participate in the Delta Dental Medicare Advantage network, am I required to accept all Medicare Advantage dental plans?
As a participating Medicare Advantage provider, you will be required to treat patients with coverage through any Delta Dental Medicare Advantage plan, including those administered by other Delta Dental member companies. Please refer to the DDOR Medicare Advantage Partnerships section above for a list of MA plans offered in Oregon.
The compliance attestation references offshore contractors. What or who is considered an offshore contractor?
The term “offshore” refers to any country that is not one of the 50 states or U.S. territories. CMS also clarifies that offshore subcontractors includes those who provide services performed by workers located in offshore countries, regardless of whether the workers are employees of American or foreign companies. For example, if your office uses a third-party vendor for patient eligibility and benefits verification and any employees of that vendor are located outside of the United States, the vendor would be considered an offshore contractor.
I would like to be in the Medicare Advantage network, but I do not have a compliance program. What should I do?
We understand it can be overwhelming to create and administer a compliance program, so we’re here to help! The American Dental Association has a sample compliance plan available
I am not currently keeping records for 10 years. Do I need to start now?
Yes. Per the Medicare Advantage Network Addendum, participating dental offices must keep records for a period of at least 10 years from the last date of treatment.
According to the Medicare Advantage Handbook, Medicare Advantage patients must consent prior to receiving any non-covered services. What is a non-covered service? Is a specific waiver required?
The term non-covered service applies to any procedure that is not a part of the patient’s plan benefits. For example, if the patient wanted a dental implant, but implants are not covered under the plan, the member’s signed consent for the service would be needed. Please note that frequency or annual maximum denials do not constitute a non-covered service.
No specific financial waiver is required, however, DDOR has created one in case that’s helpful for your office. You do not need to submit these with your claims, they just need to be in the members file in case they are requested due to an appeal or other kind of review request.
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Send dental claims to:
Delta Dental of Oregon
Attn: Dental Claims
PO Box 40384
Portland, OR 97240-0384
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Call Us at 888-374-8905
Or email us at dpror@deltadentalor.com