MANUAL FOR ENROLLING DENTAL PROVIDERS INTO IMPACT

Enrolling as a Medicaid Provider

Illinois Medicaid enrolls providers in the IMPACT system. Paper enrollment applications or updates are
not accepted, and email is now the primary method for provider communication. IMPACT and more
information about the enrollment process is available at:
https://www.illinois.gov/hfs/impact/Pages/ContactIMPACT.aspx

To Begin the Application Process

Prior to starting an enrollment, a certified W9 must be on file. A certified W9 must be on file with the
Comptroller for any provider receiving state/federal funds from the Comptroller for services rendered or
provided to Medicaid clients. To obtain a certified W9, complete the W9 form and then scan and email
the completed form to IMPACT.Help@illinois.gov. In the subject line put “W9 approval needed”.
Impact will then forward the W9 to the Illinois Comptroller and once it is reviewed and approved by the
Comptroller’s Office an email will be sent that the W9 has been approved and the enrollment may
begin.

To begin the enrollment, go to http://IMPACT.Illinois.gov. Anyone who needs access to the IMPACT
system will need to create a User ID and password through the single sign-on process. To begin, click on
“Create New Account”.

To view a step-by-step presentation on how to create a new account click on the following link:
https://www.illinois.gov/hfs/impact/Documents/SingleSignOnProviders.pdf. Also, general questions
about IMPACT provider enrollment can be answered by calling 1-877-782-5565 (select options 1, 2, 1, 1).

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 MANUAL FOR ENROLLING DENTAL PROVIDERS INTO IMPACT

To access the IMPACT provider portal, you must use an internet browser that is equivalent to Internet
Explorer 8 – or a more recent browser.

Enrollment Types for Dental Groups and Dental Facilities

Dental providers in Illinois may be able to enroll as a “Group” or as a “Facility, Agency, Organization”
(FAO).

First, the Group or FAO should enroll as a Medicaid provider before your individual practitioners enroll
as Medicaid providers (if they are not already enrolled with another medical group). Medicaid services
are rendered by individual practitioners, but the Medicaid payments will be sent to the Billing Provider
at the Group/FAO’s Primary Pay-To address. After the Group or FAO enrollment is completed and
approved, then the individual practitioners will enroll and “associate” with the Group or FAO .
National Provider Identifier (NPI)

The National Provider Identifier (NPI) number is a unique ten-digit identification number issued by the
Centers for Medicare and Medicaid Services (CMS) and required by the Health Insurance Portability and
Accountability Act (HIPPA) for health care providers in the United States. Providers must use their NPI to
identify themselves in all HIPAA related transactions. There are two types of NPI:

NPI Type 1- Health care providers who are individuals, including physicians, dentists, and all sole
proprietors. An individual is eligible for only one NPI.

NPI Type 2- Health care providers who are organizations, including physician groups, clinics, hospitals,
nursing homes, etc. (Group and FAO)

Group
A Group is an organization of individual providers that provides dental services. Groups will require a
Type 2 NPI. No licensing is required for this type of organization. For enrolling in IMPACT, a “Gro up”
includes a corporation, partnership, or LLC.

Step 1:

After logging into IMPACT, choose the Enrollment Type (Group) then click Submit. After clicking the
Submit button you will be directed to the Basic Information Step.

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Facility, Agency, Organization (FAO)

The “FAO” designation will apply to Clinics that are Federally Qualified Health Centers, Rural Health
Clinics, School Based/Linked Health Clinics and Public Health Departments that have Dental Services. An
FAO provider will require a type 2 NPI. FAO’s require a license.

Step 1:

After logging into IMPACT, choose the Enrollment Type (Facility/Agency/Organization) then click Submit.
After clicking the Submit button you will be directed to the Basic Information Step.

Medicaid Enrollment for Dental Groups and Dental Facilities

Step 2

Complete the Basic Information step. Once all the information has been entered click “Confirm” and
then “Finish” to complete this step.

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After successful completion of this step the system will generate a 14-digit Application ID. Application
IDs are valid for 30 calendar days; applications must be completed and submitted to the state for review
and will be used to track the status of the submitted application until the application has been
approved.

A step-by-step guide on how to enroll as a Group is at:

https://www.illinois.gov/hfs/impact/Documents/IMPACTGroup.pdf

A step-by-step guide on how to enroll as a FAO is at:

https://www.illinois.gov/hfs/impact/Documents/IMPACTFAO.pdf

If the dental group or clinic has multiple NPI’s with the same tax number, there should be a separate
enrollment for each NPI.

Email Addresses
Email is the primary mode of communication in the IMPACT system. Email address listed in IMPACT
need to be current and associated to the individual(s) who will be acting on the provider’s half. The
IMPACT system can hold up to 10 different email addresses.

Documents to Have on Hand for IMPACT Enrollment

When enrolling in IMPACT the following information will be needed to complete the application process:

Information on your organization, including the Primary Practice Location address, a Correspondence
Location, a Pay-To Location, office hours, whether ADA accessible, language spoken, communication
preferences, telephone number, email address – and similar information on all other locations.

Contact information on each of the owners, including percent of ownership, social security numbers,
address, telephone number, relationship between each owner.

Information about each owner’s interest in other entities reimbursable by Medicaid or Medicare – it is
required that ownership of 5% or more in any other Medicaid/Medicare entity be entered.

Specific information, including dates, of any adverse legal actions for each owner, including convictions,
suspensions, revocations or exclusions – even if they were expunged or appeals are pending (note: if
older lawsuits are unknown, state as such in the comments)

Licenses or certifications that your facility has that may be required (for FAO’s)

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Site Locations
When completing the Location Details section of the application, the Primary Practice Location,
Correspondence address, and Pay-To addresses will need to be listed. The same address can be used for
the Primary Practice, Correspondence and Pay-To addresses.

To list Other Servicing Location address, click on Add and enter the address information for that
locations.
For Other Servicing Location, in addition to the location address itself, a Correspondence and Pay -To
address is also required.

Specialty/Subspecialty
When enrolling as a Group, IMPACT will ask for the Provider Type, Specialty, and Subspecialty. It is
recommended you use:

• Provider Type: Group

• Specialty: Dental
• Subspecialty: No Subspecialty

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When enrolling as a FAO, IMPACT will ask for the Provider Type, Specialty, and Subspecialty. It is
recommended you use:

• Provider Type: Clinic

• Specialty: Federally Qualified Health Center, Rural Health Clinic, School Based/Linked Health
Clinic, or Public Health Department
• Subspecialty: Dental Services

•
•

Licenses
• Federally Qualified Health Centers are required to have their Health Resources and Services
Administration Award (HRSA) listed on their IMPACT enrollment. Medicare Certification and
Clinical Laboratory Improvement Amendments (CLIA) are optional to add.
• School Based/Linked Health Clinics are required to have their Public Health License/Certificate
listed on their IMPACT enrollment. Clinical Laboratory Improvement Amendments (CLIA) is
optional to add.
• Rural Health Clinics has the option to add their Clinical Laboratory Improvement Amendments
(CLIA) and/or Medicare Certification
• Public Health Departments are required to have their Public Health License/Certificate listed on
their IMPACT enrollment. Clinical Laboratory Improvement Amendments (CLIA) is optional to
add.
• No licensing is required for a Group enrollment.

Mode of Claim Submission

One of the six options must be selected to indicate how to process claims.

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Provider Controlling Interest/Ownership Details

Ownership entries must include at least one Managing Employee and one other ownership type. Owner
Relationships and Owners Adverse Action will need to be answered for each owner listed.

Complete Enrollment Checklist

All questions in the enrollment checklist must be answered either “yes” or “no” and comments made if
directed to do so.

Submit Enrollment Application for Approval

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Click “next” to confirm that all the information submitted as a part of the application is accurate. Read
through all the terms and conditions, and check the box certifying the agreement to the terms and
conditions. Then select “Submit Application”.

The application is then submitted to the IMPACT staff to review. The application number created after
completion of the Basic Information step can be used to check the status of the application by going
through the “Track Application” option.

Provider Information Sheet

Once your FAO application has been approved, a Provider Information Sheet will be generated and sent
to the correspondence address on file. This document contains information that will be needed to file
and submit claims. Do not disregard this document.

Groups do not receive Provider Information Sheets.

Enrollment Timeline and Commitment

All providers are required to update the license expiration date when licenses expire. It is
recommended that providers log into IMPACT and update license(s) expiration dates when the license is
renewed. Not updating the license expiration date will result in the inactivation of your account.

The enrollment into IMPACT is not a contract – it is an opportunity to bill Medicaid.

Medicaid Enrollment by Individual Practitioners

Rendering/Servicing Provider
This information refers to the individual provider who renders services to Medicaid clients but does not
submit claims directly to the state for reimbursement. Each provider must enroll separately. A step -by-
step guide on how to enroll is at:
https://www.illinois.gov/hfs/impact/Documents/IMPACTTypicalRenderingServicing.pdf

Individual Sole Proprietor

This information refers to the individual who owns his/her own practice. An Individual Sole Proprietor
may receive payments directly or associate to Billing Providers and/or Billing Agents. An Individual Sole

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Proprietor application includes Site Locations and Provider Controlling Interest/Ownership Details. A
step-by-step guide on how to enroll is at:
https://www.illinois.gov/hfs/impact/Documents/IndividualSoleProprietor.pdf

Documents to Have on Hand for IMPACT Enrollment for Individual Practitioners

When enrolling in IMPACT the following information will be needed to complete the application
process:
• State professional license(s) – number along with the effective and expiration date
• NPI of the Billing Provider you will be associating to.

Specialty/Subspecialty
When enrolling as an individual, IMPACT will ask for the Provider Type, Specialty, and Subspecialty. It is
recommended that you use provider type “Dental”. Choose which specialty you are. Subspecialty
choose between Primary Specialty and No Subspecialty. Options for Specialties include:

• Dental General Practice

• Endodontist
• General Dentistry Anesthesia
• Oral Pathologist
• Oral Surgeon/Maxillofacial Surgery
• Orthodontist
• Pedodontist
• Periodontist
• Prosthodontist
• Dental Hygienists

A specialty license must be included in your enrollment if you are choosing a specialty other than
General Practice.

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Associate Billing Provider

Rendering Servicing providers must “associate” to a Billing Provider, which is the provider who submits
claims and/or receives payment for the individual practitioners, i.e. a Group, FAO, or even an Individual
Sole Proprietor where the dental provider performs services.

If a dental provider at your Group or FAO already has a Medicaid provider number for a different entity,
the already-enrolled provider will then need to “associate” to your Group or FAO through a
modification. A step-by-step guide on how to do a modification is at:
https://www.illinois.gov/hfs/impact/Documents/IMPACTEnrollmentModification.pdf.

License/Certification
Individual Practitioners are required to have their state professional license listed on IMPACT with the
appropriate effective date and expiration date of the license.

Taxonomy Details
A taxonomy code for the specialty from the National Uniform Claim Committee Taxonomy Code list.
Choose the code that best describes you as a provider. A couple examples are listed below.

• Dentist - 122300000X
• Oral and Maxillofacial Surgery - 1223S0112X

Associate MCO Plan

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Enrolling as a Dental provider you must associate with DentaQuest of Illinois, LLC. The Plan ID you would
add is: 2000001

Complete Enrollment Checklist

All questions in the enrollment checklist must be answered either “yes” or “no” and comments made if
directed to do so.

Submit Enrollment Application for Approval

Click “next” to confirm that all the information that you have submitted as a part of the application is
accurate. Read through all the terms and conditions, and check the box certifying that you agree to the
terms and conditions. Then select “Submit Application”.

The application is then submitted to the IMPACT staff to review. The application number you were given
at the beginning of the process can be used to check the status of the application by going through the
“track application” option.

Provider Information Sheet

Once the Rendering Servicing application has been approved, each Associated Billing Provider that is
listed will receive a Provider Information Sheet. Individual Sole Provider Information Sheets will go to
the Primary address that is listed on the location step and to the address that is listed on the Associated
Billing Provider you may have listed. Do not disregard this notice.

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