CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Provider Credentialing and Recredentialing Policy

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Defines BCBSRI's requirements and processes for credentialing and recredentialing health care providers seeking participation or continued participation in the BCBSRI network, including required documentation and timelines.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProvider Credentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeAdministrative / No material change

Effective DateJan 18, 2023

Last ReviewJan 18, 2023

Next Review DateN/A

Key ActionApplicants are notified of application status every 15 days and within 5 business days once the application is deemed complete.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45 daysDecision timeframe (new provider)

180 daysMax age of documentation

$1M / $3MLiability insurance

2 yearsRecredentialing initiation

15 daysStatus notifications

Credentialing and Recredentialing Criteria

Elements required for a complete application and administrative set‑up (per OHIC and BCBSRI requirements):

Provider demographics: name and current mailing address (documentation must be dated within 180 days).

Professional liability insurance: minimum $1,000,000 each occurrence and $3,000,000 aggregate with a carrier licensed in the state of practice or approved by BCBSRI.

Medical license: copy of current medical license attached to the application.

Federal DEA certificate: valid, unrestricted DEA certificate if applicable to the applicant's specialty in each state in which he/she practices.

Board certification: if board certified, provide documentation indicating board certification.

Education/training: applicant reviewed at highest level of education completed; resident graduates who meet other requirements may be offered transitional status effective upon successful graduation.

Hospital privileges: admitting privileges at least one contracted hospital or a plan to admit BCBSRI members to a contracted hospital; primary hospital privileges will be verified.

History disclosures: history of any revocation, suspension, probationary status or other disciplinary action regarding license/registration/certificate; history of professional liability claims and descriptions of any settlements or judgments.

Administrative documents required for set‑up in BCBSRI system: signed BCBSRI Participating Provider Agreement, W‑9, Type II NPI (if applicable), EIN confirmation letter (if name/TIN mismatch), Email Update Form, EFT form with cancelled check (unless billing with participating group).

Coverage and hours requirements: after‑hours coverage for PCPs; 24/7 coverage depending on provider type; PCP office hours minimums (20 hours/week or 3 days/week) and appropriate coverage arrangements.

Site visit/desk audit: applicable for new practices or new locations within the BCBSRI network.

Application processing and notifications: applicants are notified every 15 days of application status; applicant notified within 5 business days once application is deemed complete; if approved, effective date is day following Credentialing Committee approval and notice sent within 10 business days; if required components are not provided the application will be discontinued and provider must restart the process.

Timelines and recredentialing: decision for new providers issued within 45 calendar days of receipt of a complete application; BCBSRI initiates recredentialing on the 2‑year anniversary to meet NCQA 3‑year requirement.

Process rules: providers denied or terminated for cause cannot reapply within 12 months of denial/termination; denial/termination notices include reasons and appeal rights as applicable.

Professional Liability and Coding Requirements

inv-02: Professional liability insurance minimums

Minimum per-occurrence limit$1,000,000 each occurrence

Minimum aggregate limit$3,000,000 aggregate

Carrier requirementInsurance carrier licensed in the state of practice or approved by BCBSRI

Policy applicabilityRequired professional liability coverage for applicants as part of completed application requirements

Applicant Notifications and Timelines

Documentation Required

Application status and notification timeline

Upon receipt of an application, BCBSRI will provide applicants with status updates every 15 days. Once an application is deemed complete, BCBSRI will notify the applicant within 5 business days and present the application to the next scheduled Credentialing Committee. If the Credentialing Committee approves, the effective date is the day following committee approval and the applicant will be sent notice within 10 business days. If required components are not provided, the application will be discontinued and the provider will be notified; reinstatement requires restarting the process.

Status updates to applicants every 15 days during processing.
Notice to applicant within 5 business days after application is deemed complete.
If approved by Credentialing Committee, effective date is day after approval and approval notice sent within 10 business days.
Applications missing required components will be discontinued and require restart to reapply.

Completed Application Definition

inv-04: Completed application

DefinitionCompleted credentialing/recredentialing application

Required elements (examples)Provider demographics, medical license, professional liability insurance, DEA certificate (if applicable), education/training, hospital privileges

OHIC required elementsElements marked with * in application requirements are required per OHIC guidelines

Use in processCredentialing Committee reviews only completed applications; decision timeline begins upon receipt of a complete application

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProvider Credentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeAdministrative / No material change

Effective DateJan 18, 2023

Last ReviewJan 18, 2023

Next Review DateN/A

Key ActionApplicants are notified of application status every 15 days and within 5 business days once the application is deemed complete.

SourceLink

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