Medicare Out-of-Network Provider Resources

Centene Dental Services accepts claims from Out-of-Network (OON) dental providers in designated Medicare markets:

What is covered?

Before rendering services, confirm that the member has OON dental coverage or the claim may be denied.

For Medicare Advantage plans there are 3 ways to look up coverage:

For Wellcare by Allwell plans, there are 3 ways to look up coverage:

For Illinois and Ohio MMP plans, there are 2 ways to look up coverage:

  • Check the member’s Member Handbook for OON coverage rules and benefit descriptions
  • Look up specific covered codes using our Dental Benefits CDT Search tool. Select the Active Year, the Business (“Medicaid” in the drop down menu), State, and Product.

How do I confirm eligibility? 

Call Provider Services to confirm member eligibility for OON coverage.

StateHealth PlanCustomer Service (Provider and Member)
ILMeridian Medicare-Medicaid Plan (MMP)833-522-0132
MAWellcare833-408-2624
MEWellcare833-393-1623
MOWellcare855-434-9240
MOWellcare by Allwell855-434-9240
NCWellcare833-813-0532
NEWellcare833-605-2784
NHWellcare833-795-0256
OHBuckeye Health Plan - MyCare Ohio (MMP)855-659-6663

How do I submit an OON claim?

All dental claims should include the following information:

  • Member’s name, ID number and date of birth 
  • Rendering and billing provider’s name, location and service setting, NPI, Tax Identification Number (TIN), and signature 
  • Date of service and current ADA dental codes for each service line
  • All required identifiers (quadrants, tooth numbers, and surfaces)

Note: The provider’s W-9 form is preferred, but not required, to expedite OON claims processing.

There are 2 ways to submit eligible OON claims:

  • Electronic claim submission through selected clearinghouses using Centene Dental Payor ID number 46278 
  • Paper claims submission 
    • Claims must be submitted on an original 2012 ADA Form or newer version (photocopies will not be accepted). 
    • Mail the paper claim to
      Centene Dental Medicare
      P.O. Box 23768
      Tampa, FL 33623-37

Dos and Don’ts of paper claims submissions

Do

  • Mail the paper claims to the correct P.O. Box number
    Centene Corporation Dental Medicare
    P.O. Box 23768
    Tampa, FL 33623-37 
  • Attach any supporting documents 
  • Submit all claims in a 9” x 12” or larger envelope 
  • Type all fields completely and correctly
  • Submit a current 2019 or later ADA claim form 

Don’t

  • Submit handwritten claim forms 
  • Fax claim forms 
  • Submit photocopied or carbon copied claim forms 
  • Use red ink or highlighter on the claim form
  • Provider extraneous or circled information

Out-of-network (OON) Payment

  • A 90-day grace period will be allowed to cover OON services needed for continuation of care. Check the “What is Covered?” section above for plan benefit information. 
  • PPO-OON claims are adjudicated using the in-network fee schedule up to the plan maximum, less any member responsibility. The member is responsible for any additional amounts. For example: the billed amount is $500. The in-network fee schedule is $300. The member has a 50% coinsurance = $150. The plan pays $150. The member is responsible for the remaining $200 balance owed. Total member payment responsibility in this scenario is $350. 
  • The OON provider can submit claims directly to Centene Dental Services or require the member to pay upfront. The member will need to submit using the Direct Member Reimbursement Form.

Appeals

Contracted Providers

In accordance with the Medicare managed care regulations, contracted providers DO NOT have Medicare appeal rights for payment disputes. However, Centene Dental Services has a review process to address any contracted provider claim issues. Requests for contracted provider claim reviews must be received by Centene Dental within 120 days from the date of this Explanation of Payment (EOP). A copy of this EOP and supporting justification or documentation (such as medical records) must be submitted with the review request.

Non-Contracted Providers

In accordance with the Medicare managed care regulations, non-Contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which Centene Dental has denied payment.

All requests for payment appeals must include a completed and signed Waiver of Liability (WOL) statement. The WOL statement can be found at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/2012241010-xv-model_waiverofliability_ma_feb2019v508.pdf. Centene Dental cannot begin the appeals process until a completed and signed WOL is received. Requests for appeals that do not include a WOL will be issued a Notice of Dismissal of Appeal request.

A copy of this EOP and any other supporting document (such as medical records, when applicable) must be submitted with the appeal request.  Centene Dental must make a decision regarding the appeal within 60 calendar days from the date the appeal request was received.

Addresses for appeal requests

Mail your appeals requests and all required documentation to the applicable P.O. Box below.

Health Plan Medicare Provider Claim Appeals Non-Participating (Non-Par) Providers OnlyMedicare Provider Claims Reconsiderations Participating (Par) Providers Only
WellcareWellcare Provider Appeals
P.O. Box 31368
Tampa, FL 33631-3368		Centene Dental Medicare Claims – WellCare Medicare
P.O. Box 23768Tampa, FL 33623-3768
 
Wellcare By Allwell (MO only)Grievance and Appeals – Medicare Operations
P.O. Box 3060
Farmington, MO 63640-3822
Buckeye Health Plan - MyCare Ohio Medicare-Medicaid Plan (MMP)Centene Dental Services
Attn: MMP Appeals
P.O. Box 22687
Tampa, FL 33622-2687
Meridian Medicare-Medicaid Plan (MMP), Illinois

Additional resources

Additional appeals and reconsideration information is available on our website.

Plan Specifics

Join our Network

To become a participating provider and have your information included in our provider directory, please email our Network Development team at Dentalnetwork@centene.com or visit Join Our Network.