Confidential Fee Schedule Form – Fill Out and Use This PDF

Confidential Fee Schedule Form PDF Details

About the Delta Dental Confidential Fee Schedule Form

This form establishes a clear agreement between dental providers and Delta Dental of Minnesota regarding fees charged for dental services to insured patients. Dental providers must declare that their submitted fees represent standard charges applied to all patients, ensuring consistency and transparency across Delta Dental plans.

Dental Procedures and CDT Codes Covered

Updated to incorporate CDT 2015 code terminology, the form covers comprehensive listings of dental procedures across all major categories: diagnostics, preventive care, restorative procedures, endodontics, periodontics, prosthetics, maxillofacial prosthetics, and implant services. Each procedure code requires an associated standard fee, which becomes the fee schedule on file with Delta Dental.

Provider Requirements and Filing Rules

Dental providers must include their license number, Tax ID, and all practice locations where Delta Dental patients are seen. The MinnesotaCare provider tax must be built into filed fees. Fee schedules must be submitted at least 30 days before the effective date, and providers may revise their fee schedule no more frequently than every six months. Signing the form confirms the provider's agreement to these network billing policies.

How to Complete the Confidential Fee Schedule Form

Completing this form requires four key steps: gather provider information (name, license number, Tax ID, all practice locations); list standard fees for every applicable dental procedure code; confirm that filed fees include the MinnesotaCare provider tax; and sign the certification confirming that submitted fees represent actual charges to all patients, not just non-covered services or Delta Dental network cases.

Frequently Asked Questions

Who must file a confidential fee schedule? Dental providers contracted with Delta Dental of Minnesota must file this form whenever they want to update their fee schedule with the network, at least 30 days before the new fees become effective.

Can fees be revised at any time? No. Fee schedules cannot be revised more frequently than every six months. This policy ensures consistency for both the dental provider and Delta Dental insurance plans.

Where can I find related dental forms? Dental providers may also need the ADA Dental Claim Form for individual claim submissions, the CMS-1500 Health Insurance Claim Form, or the ADA Dental Form for additional provider documentation.