Join Our Provider Network – Dental Providers

This submission is a request for participation only and not the formal credential application.
Please allow up to 10 business days for a response.

Select a provider type: Ancillary Providers Physicians and Extenders (CRNP, CNM, PA, Pharmacist) Dental Providers

***Select a provider type: Ancillary Providers Physicians and Extenders (CRNP, CNM, PA, Pharmacist) Dental Providers

* Indicates required field

Providers that utilize CAQH must enter their CAQH Provider ID in the space below. UPMC Health Plan will retrieve the provider's CAQH application for credentialing before you can complete the rest of the form. Please ensure CAQH has recently been attested, all documentation is current, and UPMC has authorization to view the application. CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

CAQH Provider ID*

Submitter Contact Information

First Name*

Last Name*

Email*

Phone*

Ext

Street Address*

City*

State*

ZIP*

Provider Information – All providers fill out this section

Physician Information

First Name*

Middle Initial

Last Name*

Suffix

Degree* Degree

Date of Birth

PROMISe ID

Medicare Number

NPI Number*

Provider Type*

Please indicate any additional services you are licensed and/or certified for and intend to offer to UPMC Health Plan members. Please recognize that offering these services may require the provision of additional documentation for credentialing.

Specimen Collection/Labs
Immunizations
Tobacco Cessation Counseling
Substance Abuse Screening and Referral
A1C Testing

Primary Specialty* Primary Specialty* Primary Specialty* Primary Specialty*

Subspecialty Subspecialty* Secondary Specialty

Please be aware that you may not qualify to be contracted for all the products you have selected.

PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products.

Selected Products*

If you are an Oral & Maxillofacial Surgery provider or an Ophthamologist, please fill out our Medical provider form.

Practice Information

Please list locations where provider regularly sees patients.

More than two office locations?*
Primary Practice:

Practice/Group Name*

Street address*

City*

State*

ZIP*

Servicing Counties*

Additional Practice States

Tax ID*

Practice Type*

Other Providers in Practice*

If yes, participating in UPMC HP

FQHC/RHC Please choose one*

FQHC/RHC NPI #

Practice Location Status*

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Secondary Practice:

Practice/Group Name

Street address

City

State

ZIP

Servicing Counties

Additional Practice States

Tax ID

Practice Type

Other Providers in Practice

If yes, participating in UPMC HP

FQHC/RHC Please Choose One

FQHC/RHC NPI #

Practice Location Status*

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Additional Practice:

Practice/Group Name*

Street address*

City*

State*

ZIP*

Servicing Counties*

Additional Practice States

Tax ID*

Practice Type*

Other Providers in Practice*

If yes, participating in UPMC HP

FQHC/RHC Please choose one

FQHC/RHC NPI #

Practice Location Status*

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Additional Practice:

Practice/Group Name*

Street address*

City*

State*

ZIP*

Servicing Counties*

Additional Practice States

Tax ID*

Practice Type*

Other Providers in Practice*

If yes, participating in UPMC HP

FQHC/RHC Please choose one

FQHC/RHC NPI #

Practice Location Status*

Medicare numbers are not currently required for UPMC Dental Advantage applicants to accept our Medicare product.

Providers that utilize CAQH may enter their CAQH provider ID in the space below. After review of the participation request submitted, UPMC Health Plan will retrieve the provider’s CAQH application for credentialing.

CRNPs, CNMs, and PAs: Please attach a copy of the collaborative agreement to the CAQH application documentation.

Oral surgery providers will need to complete credentialing with UPMC Health Plan for Medical and SKYGEN/UPMC Health Plan Dental Advantage for routine dental products.

CAQH Provider ID*

Please note, PROMISe ID and Medicare numbers are required to participate with Medicaid and Medicare Products

By submitting this request for participation, I hereby attest that all of the information I am about to submit is true and accurate to the best of my knowledge. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from UPMC Health Plan should I be approved.

By checking this box, I, [_______________], consent to receive the status of my provider credentialing status via email communication. I understand that in the event the email provided does not allow for communications to be received, I instead will receive a letter communicating my credentialing status. In addition, by submitting this request for participation, I hereby attest that all of the information I am about to submit is true and accurate to the best of my knowledge. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from UPMC Health Plan should I be approved.

Please Consent

Please retype your email to confirm *

Please provide email address

Join Our Provider Network – Dental Providers

Submitter Contact Information

Physician Information

Please indicate any additional services you are licensed and/or certified for and intend to offer to UPMC Health Plan members. Please recognize that offering these services may require the provision of additional documentation for credentialing.

Practice Information

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