Out-of-Network Provider Resources
Envolve Dental accepts claims from Out-of-Network (OON) providers in designated markets for certain products. Be sure to confirm the member’s eligibility for OON services against the Summary of Benefits before proceeding with any services, or the claim may be rejected.
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.
Submit eligible OON claims in one of these formats:
- Electronic claim submission through selected clearinghouses: Payor ID 46278
- Paper claims submission
For timely processing of your paper claims, please be sure to:
- Use the correct PO Box number (refer to plan specifics)
- 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 (except in those states that allow 2012 or later)
Envolve Dental will NOT be able to accept the following paper claims:
- Handwritten claim forms
- Faxed claim forms
- Photocopied or carbon copied claim forms
- Claim forms using red ink or highlighter
- Claim forms with extraneous or circled information
Please contact Customer Service with any questions or to confirm member eligibility for OON coverage.
To become a participating provider and have your information included in our provider directory, please email our Network Development team at firstname.lastname@example.org or visit Join Our Network.