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

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.

• 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

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

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

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

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

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

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

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

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

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

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

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