​​​​​​​​​​​​​​​​​​​Dental Application Information

Dental providers may apply for enrollment in the Medi-Cal Fee-For-Service program as individuals, group providers, rendering providers, ordering/referring/prescribing providers, or crossover-only providers by submitting an electronic application through the Provider Application for Validation and Enrollment (PAVE) online enrollment portal, along with all supporting documentation. For more information, please see the regulatory provider bulletin titled, “Upda​ted Requirements and Procedures for the Enrollment of Medi-Cal Dental Providers​."

DHCS no longer accepts paper applications from dental providers as of October 31, 2022.

Dental providers include licensed dentists, registered dental hygienists, registered dental hygienists in alternative practice, and registered dental hygienists in extended functions. However, dental assistants, registered dental assistants, or registered dental assistants in extended functions are not authorized to enroll in or bill Medi-Cal directly.

Dental Provider Resources for PAVE

• Introduction to PAVE for Dental Providers
• Basic Functions in PAVE for Dental Provider​s​
• Demo 2: Intro to PAVE Dental FAQs​​​
  

Application Requirements for Dental providers

All dental applicants requesting enrollment, changes to enrollment, or continued enrollment in the Medi-Cal Fee-For-Service program must submit an e-Form through the PAVE online system, available at the PAVE website.

Preferred Provisional Provider Eligibility

Licensed dentists may request, and provide documentation and verification for, consideration for enrollment in the Medi-Cal program as a Preferred Provisional Provider. Preferred Provisional Provider status shortens the deadline for a DHCS response from 180 days to 150 days. However, all program requirements still need to be met. Preferred status may be met if all of the following statements are true:

• The applicant holds a current license as a dentist issued by the Dental Board of California, which has not been revoked, whether stayed or not, suspended, placed on probation, or subject to other limitation;
• The applicant is currently enrolled as a dental provider by a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975;
• The applicant has never had revoked and/or suspended privileges through the California Medicaid program Medi-Cal Dental; and
• The applicant does not have any adverse entries in the Healthcare Integrity and Protection Data Bank/National Practitioner Data Bank (HIPDB/NPDB).​​
  

University Enrollment

University providers are accredited University dental schools. These providers must indicate within the e-Form application that they are applying as a University provider and upload faculty permit(s) or a letter from the University appointing the dental director(s).

Rendering Physician Enrollment

Physicians rendering services to dental provider groups must submit an e-Form application as a rendering provider linking them to the dental provider group and are required to attach a valid physician/surgeon license as well as a valid Medical General Anesthesia permit.

Specialized Enrollments

A “facility-based provider" is defined as a natural person or professional corporation enrolled as a provider who renders services to Medi-Cal beneficiaries exclusively in one or more licensed health facilities or health-related facilities. Details on the requirements and procedures for this type of enrollment are outlined in the regulatory provider bulletin titled, "Updated Requirements and Procedures for Enrollment as a "Facility-Based Provider​​"." Facility-based providers must indicate within the e-Form application that they are applying for enrollment as a facility-based provider and submit the attestation letters outlined in the aforementioned provider bulletin.

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​School-based providers offer services to elementary, middle, or high school students on school grounds. These providers must enroll using the school address as their service address, indicate within the e-Form application that they are applying as a school-based provider and upload a signed contract between the school and the provider.​

​Mobile clinics are required to indicate that they are applying for enrollment as a mobile dental clinic within the e-Form application. These providers are also required to:

• Enter their mobile dental clinic permit number issued by the Dental Board of California and attach a legible copy;
• Attach their vehicle DMV registration, as required by law; and
• Attach their vehicle insurance, as required by law.

• Registered Dental Hygienists in an Alternative Practice

Licensing

Prior to applying to Medi-Cal, first check the Dental Board to ensure you meet all of the licensing requirements shown under the tab, "Licensees".

Required Documents

1. Current California Dental, Registered Dental Hygienist, Registered Dental Hygienists in Alternative Practice, and Registered Dental Hygienists in Extended Functions License of applicant or provider. Please note out-of-state providers will need to provide a copy of their professional license applicable for their state.
2. Driver's License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider.
3. Federal Employer Identification Number (FEIN) verification, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer's Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on the application must match the name on the IRS-generated document. For further information, please visit the IRS or call them at (800) 829-4933.
4. Local Business License, Tax Certificate, and Permit for any city and/or county where business activities are conducted. Note: The name and business address of the applicant or provider on the application must match the business name and business address on all local licenses and permits. For further information, please contact your city business license office and/or visit the California State Association of Counties Web Site and click on the "California's Counties" link, and select "County Web Sites." 
5. Recorded/stamped Fictitious Business Name Statement (FBNS), issued by the county where the principal place of business is located, if using a fictitious business name AND the business name is different from the legal name on your application. For example, in the case of a corporation, any name other than the corporation name on record with the Secretary of State requires a FBNS. Note: The business name and business address of the applicant or provider on the application, all local business licenses/permits, and the FBNS must match. To determine the applicable county agency where fictitious business names are filed, please visit the California State Association of Counties Web Site and click on the "California's Counties" link, and select "County Web Sites." 
6. Fictitious Name Permit (FNP), issued by the appropriate board (e.g., Dental Board of California and Dental Hygiene Board of California), if applicable. To determine whether a FNP is applicable, please visit the Dental Board of California or Dental Hygiene Board of California web site.
7. Seller's Permit issued by the California State Board of Equalization, if applicable. Note: The business name and business address of the applicant or provider on the application must match the business name and business address on the seller's permit. For further information, call the Board of Equalization at (916) 445-6362 or visit their Web Site.
8. Fully executed Partnership Agreement and Amendments, if your business is a partnership. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
• For a General Partnership, a list of all partners with percentage of ownership or control interest for each; or
• For a Limited Partnership, information identifying the General Partner and a list of all partners with percentage of ownership or control interest for each.
• To verify or change the name and/or status of your partnership or for further information, please visit the Secretary of State California Business Portal and click on the "California Business Search" link or other appropriate link.
9. Articles of Incorporation, if your business is a corporation. For further information, please visit the Secretary of State California Business Portal and click on the "California Business Search" link or other appropriate link.
10. Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000, unless applying for specialized enrollment (see Specialized Enrollment section above for more detailed information). Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on the application must match the insured's name and address on the certificate of insurance or declaration sheet.
11. Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, effective dates, and limits of coverage. Note: The provider's name, as it appears on the professional license, must also show on the verification of the professional liability insurance.
12. Certificate of Workers' Compensation Insurance is required by California law, if your business has one or more employees, unless applying for specialized enrollment (see Specialized Enrollment section above for more detailed information). Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, and effective dates. If no Workers' Compensation insurance is required, an explanation must be provided. Note: The name of the applicant or provider must match the insured's name on the certificate of insurance.
13. Signed Lease Agreement, if business premises are not owned by the applicant or provider, unless applying for specialized enrollment (see Specialized Enrollment section above for more detailed information). Note: The name and business address of the applicant or provider must match the lessee's name and address on the lease agreement.
    
14. Successor Liability with Joint and Several Liability Agreement (DHCS 6217​), if applicable.
    
15. Additional documents for Specialized Enrollment

• ​Facility-Based Dental Provider En​​​​​​rollment

Facility-based providers must indicate within the e-Form application that they are applying for enrollment as a facility-based provider and submit the attestation letters outlined in the aforementioned provider bulletin.

• ​​School-Based Dental Provider Enrollment

​​School-based providers must enroll using the school address as their service address, indicate within the e-Form application that they are applying as a school-based provider and upload a signed contract between the school and the provider.​​

• ​​​Mobile Dental Clinic Enrollment

​Mobi​​le clinics are required to in​dicate that they are applying for enrollment as a mobile dental clinic within the e-Form application. These providers are also required to:

• Enter their mobile dental clinic permit number issued by the Dental Board of California and attach a legible copy;
• Attach their vehicle DMV registration, as required by law; and
• ​Attach their vehicle insurance, as required by law.​
• ​​Registered Dental Hygienists in Alternative Practice Enrollment

​​​Registered dental hygienists in alternative practice who provide services solely at residential facilities, residences of the homebound, group homes, licensed health facilities, or as otherwise permitted by B&P Code, Sections 1925 and 1926, may enroll using an administrative location address as their service address and may apply for exemptions to certain established place of business requirements by submitting the attestation outlined in the aforementioned provider bulletin.