July 2021 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
  
  
• Provider TeleDentistry Resources
  
  
• Provider COVID-19 Resources

• 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

• On-Line Provider Portal User Guide
• National Provider Reference Guide
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Electronic Fund Transfer (EFT) Form
• Provider Complaint and Dispute Form (fillable)
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Specialty Care Referral Form
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• California Provider Reference Guide
• Clinical Criteria Guidelines and Practice Parameters
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• CMS Appointment of Representative Form
• Consent for Non-Covered Treatment - English
• DHCS 5300 Application Form
• DHCS 6216 Application Form
• Electronic Fund Transfer (EFT) Form
• Employee Language Pre-Screening Tool Kit
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• Language Assistance Program (LAP) Notice
• LDP Provider Credentialing Application
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Brochure
• Orientation Brochure - Health Net
• Provider Compliance Training & Attestation
• Provider Complaint and Dispute Form (fillable)
• Provider DIV FAQ's
• Secure Use and Transmission of Electronic PHI
• Specialty Care Referral Form
• Enrollment FAQs
• POE FAQs
• POE User Guide

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

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Spanish
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Specialty Care Referral Form
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

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
• Enrollment FAQs
• POE FAQs
• POE User Guide

Provider Manuals

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

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Illinois Orthodontic Criteria Index Form
• 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
• Enrollment FAQs
• POE FAQs
• POE User Guide



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

• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orthodontia Scoring Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• TOC - Orthodontic Transition of Care and Form

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• On-Line Provider Portal User Guide
• National Provider Reference Guide
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Provider Complaint and Dispute Form (fillable)
• Electronic Fund Transfer (EFT) Form
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• Grievance Form - English
• Grievance Form - Spanish
• Handicapping Labio-Lingual Deviation Index (HLD) Score Sheet
• Instructions for the HLD Index Measurements
• 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
• MO Orthodontic Continuation of Care Submission Form
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• OrthoCAD Submission Form
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Site Application
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Caries Risk Assessment Forms (ages 0-6 and over 6)
• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Criteria Guidelines and Practice Parameters
• Consent for Non-Covered Treatment
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• CMS Appointment of Representative Form
• Electronic Fund Transfer (EFT) Form
• ECHO Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) Form
• ECHO EFT-ERA Reference Guide
• Member Grievance & Appeals Form - English
• Member Grievance & Appeals Form - Spanish
• Provider Grievance Form
• Informed Consent for Alternative Treatment Form - English
• Informed Consent for Alternative Treatment Form - Chinese
• Informed Consent for Alternative Treatment Form - Spanish
• Medicaid Services Manual Chapter 1000 Dental
• NV Medicaid Orientation Brochure
• NV Medicaid Provider FAQs
• NV Medicaid Provider Training
• NV Medicaid Provider Reference Guide
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Secure Use and Transmission of Electronic Protected Health Information Policy
• Specialty Care Referral Form
• Enrollment FAQs
• POE FAQs
• POE User Guide

• ADA Claim Form
• AdultCare & KidCare - Oral Health & Wellness Tips
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• 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
• National Provider Reference Guide
• On-Line Provider Portal User Guide
• Opioid Risk Tool
• Orientation Medicare Advantage email
• Provider Complaint and Dispute Form (fillable)
• Provider Compliance Training & Attestation
• Provider DIV FAQ's
• Enrollment FAQs
• POE FAQs
• POE User Guide

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
• Clinical Guidelines for Prescribing Fluoride Supplements for Caries Prevention
• Useful Tools for a Compliant Medicaid Provider: A Presentation for Dental Providers

Reference Materials

• NJ Periodicity Schedule (Dental Services for Children NJ FamilyCare)
• NJ FamilyCare Dental Benefits Grid
• ECHO EFT-ERA Reference Guide
• Enrollment FAQs
• 2022 NJ FamilyCare Clinical Criteria Policy
• 2023 NJ FamilyCare Clinical Criteria Policy
• 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

Provider Manuals

• National Provider Reference Guide
• NJ Family Care Provider Reference Guide - Aetna Better Health
• NJ FamilyCare Provider Reference Guide - Amerigroup
• NJ FamilyCare Provider Reference Guide - WellCare

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

• 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
• Medicaid Enrollment Form
• Provider Compliance Training & Attestation
• Provider Complaint and Dispute Form (fillable)
• 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 EFT-ERA Reference Guide
• 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
• Elderwood Health Plan Provider Quick Reference Guide
• Highmark BlueCross BlueShield of Western New York Provider Reference Guide
• Kalos Health Plan Provider Quick Reference Guide
• Montefiore Diamond MLTC Reference Guide
• National Provider Reference Guide
• Empire BlueCross BlueShield HealthPlus 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