CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Credentialing and Recredentialing Policy

Defines BCBSND requirements, procedures, committees, and standards for credentialing and recredentialing Professional Health Care Providers and Institutional/Ancillary Providers seeking participation with Blue Cross Blue Shield of North Dakota. Applies to all licensed providers seeking participation with BCBSND.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyCredentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit a completed, signed and dated credentialing or recredentialing application with required documentation (licenses, certifications, malpractice evidence, W-9 when applicable) and ensure primary source verification documents are dated within 120 days of Committee review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36recredentialing frequency

180max application signature age (days)

120max verification doc age (days)

51%committee quorum

45delegate report timeframe (days)

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30provider notification after decision (days)

Policy Snapshot

This policy, Credentialing and Recredentialing of Providers, defines Blue Cross Blue Shield - North Dakota (BCBSND) requirements, processes, committees, and standards for credentialing and recredentialing Professional Health Care Providers and Institutional/Ancillary Providers seeking participation with BCBSND. It sets verification, documentation, and review procedures to confirm licensure, education, professional standing, accreditation and malpractice coverage, and outlines oversight, monitoring, and committee responsibilities. The policy is informational and the current status is CURRENT (last reviewed 2026-01-28).

PolicyCredentialing and Recredentialing of Providers

PayerBlue Cross Blue Shield - North Dakota

StatusCURRENT

Last review2026-01-28

EffectiveN/A

Next reviewN/A

Criteria and Clinical Rules

This document is provided as informational guidance on BCBSND's credentialing and recredentialing processes and is not itself a coverage determination. There are no decision-based criteria trees embedded in this policy; rather, it describes required documentation, verification timeframes, committee roles, and program standards used to assess provider participation.

Numeric and Timing Thresholds

Recredentialing interval36 months

Application signature currencySignature not more than 180 calendar days prior to Committee review

Primary source verification currencyDocumentation dated no more than 120 calendar days prior to Committee review

Provider notification timeframe (initial credentialing)Within 30 calendar days of Committee decision

Provider appeal submission window30 days from receipt of denial/restriction notice

Delegate report timeframeWithin 45 days of Delegate approval of Provider

Directory display for new providersWithin 30 calendar days of credentialing and contracting completion

What Providers Must Do

Documentation Required

Application and attestation requirements

Providers must submit a completed credentialing or recredentialing application that is signed and dated (signature cannot be more than 180 calendar days prior to Committee review). Applications must include required supporting documentation such as licenses, certifications, malpractice/general liability evidence (including coverage amounts and effective/expiration dates), and a W-9 for groups when applicable. Applications must disclose professional claims history, disciplinary actions, limitations on privileges, gaps in professional history, and any other required attestation fields.

Signature on application cannot be dated more than 180 calendar days prior to Committee review
Include licenses, certifications, malpractice/general liability evidence with coverage amounts and effective/expiration dates
Groups must include a W-9 when applicable
Disclose professional claims history, disciplinary actions, privileges limitations, and gaps in professional history

Documentation Required

Primary source verification

BCBSND will primary-source verify license, education/training, board certification (if applicable), sanction activity (Medicare, Medicaid, LEIE, SAM), NPDB, accreditation status, and criminal background/licensure screening for MD/DOs. All primary source verification documentation must be dated within 120 calendar days prior to Committee review.

Defined Terms

Professional Health Care ProviderAn individual who provides professional health care services and is licensed, certified, or registered by the state in which the services are performed. Listing does not guarantee payment under BCBSND plans.

Institutional/Ancillary ProviderA facility or entity that provides health care services (e.g., acute care hospitals, freestanding dialysis centers, ambulatory surgery centers, home health agencies, etc.) and must meet licensure, accreditation, and malpractice requirements as specified.

Acceptance DateThe effective date of the Agreement stored in a provider organization's file, equal to the receipt date of the Agreement unless otherwise noted.

Professional Health Care Provider (recredentialing context)Individual clinicians (e.g., MD, DO, NP, PA, dentists, allied clinicians) subject to credentialing/recredentialing requirements.

Institutional/Ancillary Provider (recredentialing context)Organizations or ancillary service providers (e.g., facilities, labs) that require accreditation, licensing, Medicare certification and malpractice coverage as applicable.

Policy Background and Scope

BCBSND's Credentialing/Recredentialing Policy ensures systematic review and verification of providers' qualifications, including education, licensure, professional standing, accessibility, utilization and quality, and describes procedures for delegated credentialing and oversight. It applies to all licensed providers seeking participation with BCBSND in North Dakota and includes specific provisions for programs such as Medicaid Expansion and Medicare Advantage where enrollment or participation requirements differ (for example, Peer Support Specialists I & II and Case Managers/Care Coordinators must be enrolled with ND Medicaid for Medicaid Expansion participation).

Policy Updates

1998Revision

Initial documented revision year included in policy revision history.

2018-02-27Revision

Policy revision recorded on 02/27/18.

2019-02-26Revision

Policy revision recorded on 02/26/19.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyCredentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Verify state license/certification, highest education/training, and board certification where applicable
Verify state and federal sanction activity (Medicare, Medicaid, LEIE, SAM) and NPDB
Criminal background/licensure screening for MD/DOs
Verification documentation must be dated no more than 120 days prior to Committee review

Documentation Required

Malpractice insurance proof

Providers and Institutional/Ancillary Providers must provide a certificate or proof of malpractice/general liability insurance showing coverage amounts and effective and expiration dates. Ambulance services may instead provide written confirmation of coverage from the North Dakota Insurance Reserve Fund (NDIRF) in lieu of the certificate.

Provide certificate/proof of malpractice or general liability insurance with coverage amounts and effective/expiration dates
Certificate or accompanying letterhead must clearly state the provider is covered
Ambulance services: NDIRF written confirmation may be accepted instead of the certificate

Prior Authorization

Medicare Advantage and Medicaid enrollment requirements

Providers participating in Medicare Advantage must participate in Medicare (may not opt-out) and have a signed agreement; Medicaid Expansion network providers must be enrolled with the State Medicaid program. Peer Support Specialists I & II and Case Managers/Care Coordinators must be enrolled with North Dakota Medicaid for participation in Medicaid Expansion products.

Medicare Advantage: provider must participate in Medicare and have a signed agreement (no Medicare opt-out)
Medicaid Expansion: provider must be enrolled with the state's Medicaid program
Peer Support Specialists I & II and Case Managers/Care Coordinators must enroll with ND Medicaid for Medicaid Expansion participation

Billing Rule

Agreement effective date and contracting

A signed Provider Group Participation Agreement must be received by BCBSND. Agreements will not be backdated except when a delay was attributable to BCBSND. The Acceptance Date in the provider organization's file equals the receipt date of the Agreement unless otherwise noted; individual providers' participation effective dates within a group may be equal to or after the Acceptance Date provided at least one provider has been credentialed.

Signed Provider Group Participation Agreement required
No backdating of Agreements except when BCBSND caused the delay
Acceptance Date = receipt date of the Agreement unless otherwise noted
Provider participation effective date within a group may be equal to or after Acceptance Date if at least one provider has been credentialed

Documentation Required

Erroneous information correction

BCBSND will notify providers if information obtained from a primary source differs from the application. Providers have the right to correct erroneous information and review supporting documentation; any deficiencies are documented and appended to the provider file.

BCBSND will contact the Provider if primary source information differs from the application
Provider may correct erroneous information and review supporting documentation
Deficiencies are documented and attached to the Provider's file

Documentation Required

Recredentialing application submission

For recredentialing, Professional Health Care Providers must return a signed and dated recredentialing application with supporting documentation; the signature cannot be dated more than 180 calendar days prior to Committee review. If the recredentialing application is not submitted within the 36‑month window, the provider record will be terminated and claims will not process; reinstatement requires an initial credentialing application.

Recredentialing occurs every 36 months; provider notified to update and return signed recredentialing application
Recredentialing signature cannot be dated more than 180 calendar days prior to Committee review
Failure to submit within 36 months results in termination of record and inability for claims to process; initial application required to reinstate

Documentation Required

Primary source verification documents

Providers must ensure primary source recredentialing documentation (licenses, board certification, DEA/CDS, hospital privileges, malpractice evidence, etc.) is current and dated no more than 120 calendar days prior to Committee review.

Primary source documents must be dated within 120 days prior to Committee review
Required documents include state license/certification, DEA/CDS (if applicable), hospital privileges, board certification or highest education/training, and malpractice evidence

Billing Rule

Claims suspension for noncompliance

If a provider fails to comply with recredentialing requirements, BCBSND will suspend and deny claims, rendering the provider liable until credentialing paperwork is received and processed as an initial credentialing file.

Noncompliance with recredentialing causes claims to suspend and deny as provider liable
Claims remain suspended until credentialing paperwork is received and processed as an initial credentialing

Prior Authorization

Provider termination for exclusion

If a provider is confirmed on federal exclusion lists (OIG/LEIE, SAM, GSA), the provider is immediately ineligible to bill BCBSND and termination is immediate without Committee review; reinstatement requires full credentialing.

Confirmation of exclusion from federal lists makes provider immediately ineligible to bill BCBSND
Termination for an OIG match is immediate and does not require Committee review
Reinstatement after exclusion requires full credentialing

Note

Appeal of denied or restricted application

A provider has 30 days from receipt of a denial or restricted participation notice to submit a written appeal with new information. QMC will review the appeal at its next scheduled meeting and will provide written notice of its decision within 10 business days. If the denial is upheld, BCBSND may report the action to NPDB and the appropriate state licensing board; if the provider does not appeal within 30 days they waive review and may reapply 18 months after denial.

30-day window to submit written appeal from receipt of denial/restriction notice
QMC reviews appeal at next regularly scheduled meeting and issues written decision within 10 business days
If upheld, action may be reported to NPDB and state licensing board
If no appeal within 30 days, provider deemed to have waived review; may reapply 18 months after denial

Documentation Required

Notification obligations for delegates

Delegates must provide BCBSND reports of credentialed/recredentialed providers (including name, designation, specialty, credentialing/recredentialing dates, and effective date) within 45 days of the Delegate's approval of the provider and must allow BCBSND audits and access to documents.

Delegate must submit reports of eligible providers within 45 days of their approval
Reports must include name, professional designation, specialty, date credentialed/recredentialed, and effective date
Delegate must allow BCBSND access to documents and be subject to oversight and audits

Documentation Required

Provider directory update obligations

Providers must promptly update demographic and practice information. BCBSND will display newly approved participating providers in the online directory within 30 calendar days of credentialing and contracting completion; removed or non‑participating providers are removed from online directories within 5 business days and from electronic versions within 30 calendar days. Updated provider information is available in provider demographics data within 48 hours of receipt.

Update demographic/practice information promptly when changes occur
Newly approved providers displayed online within 30 calendar days of credentialing and contracting completion
Participating providers not recredentialed or no longer meeting standards removed from online directory within 5 business days
Removed from electronic versions within 30 calendar days
Updated provider information available in demographics within 48 hours of receipt

An organization that has a Credentialing Delegation Agreement with BCBSND to perform credentialing/recredentialing, subject to oversight and audit.

Primary source verificationVerification of credentials via phone, internet, fax, or letter directly with the issuing/licensing body; documents must be dated within 120 days prior to Committee review.

Policy revision recorded on 01/23/20.

2021-04-28Revision

Policy revision recorded on 04/28/21.

2021-06-25Revision

Policy revision recorded on 06/25/21.

2021-11-18Revision

Policy revision recorded on 11/18/21.

2022-02-17Revision

Policy revision recorded on 02/17/22.

2022-10-17Revision

Policy revision recorded on 10/17/22.

2023-01-26Revision

Policy revision recorded on 01/26/23.

2023-06-13Revision

Policy revision recorded on 06/13/23.

2024-01-24Revision

Policy revision recorded on 01/24/24.

2024-02-28Revision

Policy revision recorded on 02/28/24.

2025-01-22Revision

Policy revision recorded on 01/22/25.

2025-02-26Revision

Policy revision recorded on 02/26/25.

2025-05-28Revision

Policy revision recorded on 05/28/2025.

2026-01-28ReviewLatest

Last review.

Credentialing and Recredentialing Policy

Policy Snapshot

Criteria and Clinical Rules

Numeric and Timing Thresholds

What Providers Must Do

Defined Terms

Policy Background and Scope

Other Policies to Review

Policy Updates