A Guide to Provider Credentialing with Blue Cross Blue Shield

This means:

• Each BCBS plan may have slightly different requirements
• You might need to credential with multiple BCBS entities
• Documentation requirements can vary by state
• Processing times differ between BCBS plans

The Foundation: What You’ll Need

Before starting your application, gather these essential documents:

Basic Documentation:

• Current state medical license(s)
• DEA registration and state DPS/CDS (if applicable)
• Board certification(s)
• Professional liability insurance declaration page
• CV showing 5 years of work history (no gaps)
• Medical school diploma
• Residency/fellowship certificates
• ECFMG certificate (if applicable)
• Government-issued photo ID
• Social Security card
• National Provider Identifier (NPI)
• CAQH ProView profile
• Medicare/Medicaid numbers (if applicable)
  

State-by-State Variations

Each BCBS plan has unique requirements.

Common variations include:

• Different liability insurance minimums
• State-specific background check requirements
• Varying site visit requirements
• Plan-specific application forms

The CAQH Foundation

Like most major insurers, BCBS uses CAQH ProView.

However, they have specific requirements:

• Complete attestation every 120 days
• Authorize all relevant BCBS plans
• Ensure consistency with state applications
• Maintain current certificates and licenses
  

Step 1: Initial Research and Preparation

1. Identify relevant BCBS plans for your practice
2. Review each plan’s specific requirements
3. Create a checklist for each BCBS entity
4. Organize documentation by plan

Step 2: CAQH Profile Setup

1. Complete all sections of CAQH ProView
2. Upload required documents
3. Authorize relevant BCBS plans
4. Set attestation reminders

Step 3: BCBS Application Submission

1. Access the provider portal for each BCBS plan
2. Complete plan-specific applications
3. Submit supporting documentation
4. Pay any applicable fees
5. Track submission dates and confirmation numbers

Step 4: Primary Source Verification

During this phase, BCBS will verify:

• Education and training
• Licensing
• Board certifications
• Work history
• Malpractice history
• Hospital privileges
• References

Timeline: Usually 45-90 days, varying by plan

Step 5: Committee Review

The credentialing committee evaluates:

• Verification results
• Practice patterns
• Quality indicators
• Compliance history

Step 6: Final Determination

Possible outcomes include:

1. Approval
2. Denial
3. Request for additional information
   

Managing Multiple Applications

• Create a master tracking spreadsheet
• Use consistent information across applications
• Maintain separate files for each plan
• Track deadlines and follow-up dates

Tips for Multi-State Providers

1. Prioritize by patient volume
2. Consider delegated credentialing
3. Use centralized document management
4. Set up a calendar for renewal dates
   

Documentation Management

• Create digital copies of everything
• Use consistent naming conventions
• Maintain a credentialing calendar
• Keep separate folders by BCBS plan
• Store confirmation numbers and reference IDs

Communication Strategies

1. Designate a primary contact person
2. Document all communications
3. Follow up every 2-3 weeks
4. Keep written records of conversations
5. Use official channels for submissions
   

Delayed Processing

If facing delays:

1. Check application status online
2. Contact provider relations
3. Verify CAQH attestation
4. Submit missing information promptly

Information Discrepancies

To resolve discrepancies:

1. Review all submissions for consistency
2. Update CAQH immediately
3. Send corrections through proper channels
4. Follow up to confirm receipt
   

Group Practice Considerations

For group practices:

• Coordinate individual provider applications
• Manage group agreement separately
• Consider delegated credentialing options
• Maintain group demographic information

Adding Practice Locations

When adding locations:

1. Notify each relevant BCBS plan
2. Update CAQH profile
3. Complete location add forms
4. Verify tax ID requirements

Recredentialing Process

Prepare for recredentialing:

• Start 6 months before due date
• Update all documentation
• Review any new requirements
• Complete CAQH re-attestation
  

Ongoing Compliance

1. Track expiration dates
2. Monitor requirement changes
3. Update information promptly
4. Maintain accurate CAQH profile
5. Document continuing education

Regular Updates

Keep BCBS informed of:

• Practice changes
• Provider status updates
• Location changes
• Tax ID modifications
• Coverage arrangements
  

Building Strong Relationships

• Establish contact with provider representatives
• Attend BCBS provider workshops
• Join provider advisory groups
• Stay informed about policy changes

Quality Reporting

• Understand quality metrics
• Participate in quality programs
• Document outcomes
• Meet reporting deadlines
  

Key Contacts

• Provider Services (plan-specific)
• Credentialing Department
• Network Management
• Technical Support

Online Resources

• BCBS plan websites
• Provider portals
• CAQH ProView
• State medical board websites
  

Common Issues and Solutions

Application Status Issues

• Check online portal
• Contact provider services
• Verify submission receipt
• Follow up systematically

Document Problems

• Review requirements carefully
• Submit current versions
• Follow format specifications
• Keep submission records

Timeline Concerns

• Start early
• Follow up regularly
• Document delays
• Escalate when necessary