Provider Network Participation Policy
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Defines which provider types and specialties are eligible to participate in BCBSMT provider networks administered by Alacura Medical Transportation Management and sets credentialing and geographic/licensure limits; affects all providers seeking participation in specified BCBSMT networks.
No material clinical or coverage changes in this revision.
Network participation and eligibility rules
Network participation criteria
Networks include or exclude specific provider types; credentialing is required for most provider types with network-specific exceptions; BCBSMT contracts with providers licensed in Montana or contiguous counties and generally does not contract with out-of-state ancillary DME, laboratory, or specialty pharmacy providers unless compelling reason.
ALL of the following
- Contracts with providers located in and licensed by the State of Montana or in contiguous counties bordering Montana as necessary to provide benefits and services.
Geographic/licensure limit applies across networks.
- BCBSMT does not contract with out-of-state ancillary DME, Laboratory, and Specialty Pharmacy providers unless there is a compelling reason.
- BCBSMT shall not discriminate with respect to participation against any health care provider acting within the scope of license; discrimination allegations must be submitted in writing for review by the Director of Network Management.
ALL of the following
- Includes all contractible provider types except: Direct Entry Midwife; Federally Qualified Health Centers; Ground Ambulance; Hearing Aid Suppliers; Rural Health Clinics; Therapeutic Group Home.
- Credentialing is required for all provider types prior to participation, except: Autism DX and/or TX Agency; Family Planning; Public Health Department.
ALL of the following
- Follows the same inclusions/exclusions as the Traditional Participating Provider Network.
- Providers must be participating in the BCBSMT Traditional Participating Provider Network to be eligible for HealthLink.
ALL of the following
- Can include all contractible provider types except: Dentists; Direct Entry Midwife; Federally Qualified Health Centers; Ground Ambulance; Hearing Aid Suppliers; Rural Health Clinics; Therapeutic Group Home.
- Providers generally must participate in the Traditional network, except: Chemical Dependency Center; Mental Health Center; Sleep Center/Lab.
- Credentialing is required for all providers in Managed Care except: Autism DX and/or TX Agency; Essential Community Providers; Public Health Department; Family Planning.
ALL of the following
- Includes all contractible provider types except listed exclusions (e.g., Acupuncturist; Autism DX/TX Agency; Birthing Center; Board Certified Behavioral Analyst; Clinical Pharmacists; Direct Entry Midwife; DME; FQHC; Ground Ambulance; Hearing Aid Suppliers; Home Infusion; Licensed Genetic Counselors; Naturopath; Physiological Lab/Cardiac Monitoring; Prostheses/Orthotics/Pedorthists; Rural Health Clinic; Skilled Nursing Facility; Wellness Screening Vendors).
- HMK providers are not required to participate in the BCBSMT Traditional Participating Provider Network.
- Credentialing is required for all physicians who participate in HMK.
- Provider Enrollment and Screening in compliance with 42 CFR 455 subparts must be completed by all provider types as applicable.
ALL of the following
- Includes all contractible provider types except listed exclusions (e.g., Acupuncturist; Autism DX/TX Agency; Birthing Center; BCBA; Clinical Pharmacists; Dentists; Direct Entry Midwife; Eating Disorders Center; Family Planning; Hearing Aid Suppliers; Hospice; Licensed Addiction Counselor; Licensed Genetic Counselor; Naturopaths; Public Health Departments; Residential Treatment Facility; Therapeutic Group Home; Wellness Screening Vendors).
- Credentialing is required for all provider types in MedicareBlue PPO except Ground Ambulance.
ALL of the following
- Invite-only networks limited to specified counties (see policy for county lists).
- Credentialing required for all provider types except Autism DX and/or TX Agency and Essential Community Providers (ECPs).
ALL of the following
- Each includes most contractible provider types but enumerate specific exclusions (examples include Ambulance - Air; Ambulance - Ground; Board Certified Behavior Analyst; Chemical Dependency Center; Clinical Pharmacists; Dentist; Dialysis Centers; Direct Entry Midwife; Eating Disorders Center; Hearing Aid Suppliers).
- TriWest does not contract with any Pediatric specialty.
- Credentialing is required for all provider types in TriWest and TRICARE except Family Planning Centers and Public Health Clinics.
ALL of the following
- BCBSMT recognizes an extensive list of provider types and specialties (e.g., Acupuncturist; Ambulance - Air/Ground; Audiologist; Autism DX/TX Agency; Birthing Center; BCBA; CNM; CRNA; Chemical Dependency Center; Chiropractor; Clinical Pharmacists; Dentist; DME; FQHC; Home Health; Hospice; Hospital; Imaging; Laboratory; Mental Health Facility; Nurse Practitioner; Occupational/Physical/Speech Therapists; Physicians; Podiatrist; Prosthetics/Orthotics; Public Health Clinic; Registered Dietician; Rehabilitation Facility; Rural Health Clinic; Skilled Nursing Facility; Specialty Pharmacy; etc.).
Billing, coding, and enrollment notes
Credentialing requirements and provider responsibilities
Credentialing required for Traditional Participating Provider Network
Credentialing is required for all provider types prior to participation in the BCBSMT Traditional Participating Provider Network, except for Autism DX and/or TX Agency, Family Planning, and Public Health Department.
- Apply for and complete BCBSMT credentialing before joining the Traditional Participating Provider Network.
- Do not assume participation rights if credentialing is incomplete; exceptions listed above do not require credentialing.
Credentialing required for Managed Care Network (with listed exceptions)
Credentialing is required for all providers in the BCBSMT Managed Care Provider Network except Autism DX and/or TX Agency, Essential Community Providers, Public Health Department, and Family Planning; additionally, most providers must participate in the Traditional Participating Provider Network (with specified clinical exceptions) prior to Managed Care participation.
- Ensure enrollment and credentialing in the Traditional Participating Provider Network unless your provider type is Chemical Dependency Center, Mental Health Center, or Sleep Center/Lab (these are exceptions to the Traditional participation requirement).
- Complete Managed Care credentialing unless your organization is one of the listed exceptions.
- Confirm whether your organization qualifies as an Essential Community Provider, Public Health Department, Autism DX/TX Agency, or Family Planning to use credentialing exception.
HMK: Physician credentialing and 42 CFR 455 enrollment/screening
For the Healthy Montana Kids (HMK) Provider Network, credentialing is required for all physicians who participate, and Provider Enrollment and Screening in compliance with 42 CFR 455 Subparts must be completed by all provider types as applicable.
- Physicians must complete BCBSMT HMK credentialing prior to participating in the HMK network.
- All provider types must complete Provider Enrollment and Screening per 42 CFR 455 Subparts when applicable.
- Note that HMK providers are not required to participate in the BCBSMT Traditional Participating Provider Network.
Credentialing required for MedicareBlue PPO (Ground Ambulance exception)
Credentialing is required for all provider types in the BCBSMT MedicareBlue PPO Provider Network except Ground Ambulance.
- Complete MedicareBlue PPO credentialing prior to participation unless your provider type is Ground Ambulance.
- Review the MedicareBlue network exclusions list to confirm eligibility before applying.
Invite-only POS networks — credentialing required with limited exceptions
The Blue Focus and Blue Options POS networks are invite-only; credentialing is required for all provider types in each POS network except Autism DX and/or TX Agency and Essential Community Providers (ECPs).
- Do not apply unsolicitedly—contact your Provider Network Consultant for invite-only enrollment.
- If your organization is an Autism DX/TX Agency or an Essential Community Provider, credentialing is not required for these POS networks.
TriWest and TRICARE credentialing exceptions and exclusions
TriWest CCN and TRICARE networks require credentialing for all provider types except Family Planning Centers and Public Health Clinics; TriWest additionally notes it does not contract with any pediatric specialty.
- If you are a Family Planning Center or Public Health Clinic, credentialing is not required for TriWest or TRICARE participation.
- TriWest explicitly will not contract with any pediatric specialty—verify network applicability before applying.
Key definitions and non-discrimination
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