Credentialing and Recredentialing of Providers
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This policy governs BCBSND's processes and requirements for credentialing and recredentialing licensed professional and institutional/ancillary providers seeking participation with Blue Cross Blue Shield of North Dakota, including committee oversight and recordkeeping.
No material clinical or coverage changes in this revision.
Participation and Credentialing Criteria
inv-01: Participation and Enrollment Criteria
Providers eligible for participation must be licensed and meet established policy requirements; certain program-specific enrollment instructions apply.
Professional Health Care Provider types
- Examples include: MD, DO, NP, PA, CRNA, CNM, CNS, DDS, DPM, OD, PT, OT, Audiologist, Psychologist, LCSW, LMSW, LPC, LMFT, LADC, LRD, RPH, and others as listed in the Professional Credentialing Guide.
Institutional/Ancillary Provider types
- Examples include: Acute Care Hospitals and subunits, Freestanding Psychiatric Hospital, IOP, PHP, Residential Treatment Centers, Ambulatory Surgery Centers, Home Health Agencies, Home Infusion Centers, Durable Medical Equipment suppliers, Independent Labs, Mobile Radiology, Long Term Acute Care, Skilled Nursing Facilities, Hospice, Dialysis Centers, Sleep Labs, Freestanding PT facilities, and other ancillary suppliers as listed in the Organizational Credentialing Guide.
inv-02: Credentialing and recredentialing criteria
Standards and required documentation for provider participation by provider type
Professional provider general requirements
- Maintain current state license/registration/certification appropriate to practice; list all licenses held and disclose any loss or disciplinary action.
- Maintain professional/general liability (malpractice) coverage at or above legal/community standard and provide certificate of insurance permitting 30 days' prior notice of change, termination or expiration.
- Provide information related to professional claims history (settlements or adverse judgments).
- No unexplained chronological gaps greater than six (6) months in recent professional career history; work history for the past five years is reviewed (or from graduation if more recent).
- Not currently excluded from state or federal programs (must report exclusions within 15 business days of receipt of OIG notice).
Professional provider verification items
- Primary source verification of licensure, education/training and board certification (if applicable).
- Maintain DEA certificate when applicable; physician foreign graduates must be ECFMG certified.
- Criminal and sanction checks, including NPDB and applicable federal/state exclusion lists.
- Maintain specialty certifications as required (e.g., NP/CNM/CNS/CRNA certification) and verify hospital privileges when applicable; compact/PSYPACT verifications used where allowed.
Provider Agreements and Setup
Signed Provider Group Participation Agreement required; backdating only for BCBSND delay
A signed and completed Provider Group Participation Agreement must be received by BCBSND; agreements will not be backdated to satisfy provider requests except where evidence shows delay was BCBSND's responsibility. The Acceptance Date (effective date) recorded in the provider organization's file equals the receipt date of the Agreement unless otherwise noted. A copy of the business W-9 must accompany the signed Agreement. Participation effective dates for individual providers in the group may be on or after the Agreement Acceptance Date provided at least one provider has been successfully credentialed.
- Agreements will not be backdated to satisfy provider requests.
- Exception: delay caused by BCBSND issuing an Agreement is the only backdating exception.
- Acceptance Date = receipt date unless Agreement states otherwise.
- Submit a copy of the business W-9 with the signed Agreement.
- Individual providers’ participation dates may be on/after Acceptance Date if one provider in the group is credentialed.
Provider setup and effective date: Committee determination, system loading, and retroactive limits
After the Credentialing Committee makes a determination, the provider's practice location(s) will be loaded into BCBSND's provider data system for claims and directory use; the effective setup date is the later of the date the provider joined the participating organization or the organization's agreement effective date. BCBSND generally limits retroactive effective dates to 90 days from receipt, unless contracting approves a longer retro date. Providers will not appear in directories until Committee or Committee Chair/designee approval.
- Only completed applications are submitted to the Committee for review.
- General 90-day retroactive limitation from application/request receipt; exceptions require contracting team approval.
- Providers are not displayed in any directory until Committee or Chair/designee approval date.
- Written notification of Committee approval or denial is sent within 30 business days of the Committee decision.
Key Definitions
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