CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Provider Credentialing and Recredentialing Policy

Defines BCBSRI requirements and processes for initial credentialing and periodic recredentialing of participating health care providers, and who is affected (prospective and current network providers).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProvider Credentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionSubmit a completed CAQH (or dental) application with required documentation including licenses, liability insurance, DEA if applicable, hospital privileges, signed participation agreement, W-9, and EFT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45 daysDecision timeframe (new provider)

180 daysSupporting docs dated within

2 yearsRecredentialing interval

$1M/$3MLiability insurance (occ/agg)

10 daysNotice after committee approval

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Credentialing and Recredentialing Criteria

Credentialing/Recredentialing Criteria and Processes

Credentialing and recredentialing are covered when ALL of the following organizational, provider, and procedural requirements are met:

ALL of the following

Maintain professional liability insurance of at least $1,000,000 per occurrence and $3,000,000 aggregate with a carrier licensed in the state of practice or approved by BCBSRI.
Attach a copy of current medical license to the application.
Provide a valid, unrestricted Federal DEA certificate if applicable to the applicant's specialty and in each state in which the applicant practices.
Primary Care Physicians must provide after-hours coverage for members; PCP office hours must be a minimum of 20 hours per week or three days per week with appropriate coverage arrangements.
Provide documentation of board certification if board certified.
Where required by provider type, maintain 24/7 coverage as applicable for the specialty.
Applicants must have admitting privileges to at least one contracted hospital or a documented plan for admitting BCBSRI members; primary hospital privileges will be verified.
Include required administrative and tax forms and agreements: W-9, signed current BCBSRI Participating Provider Agreement, EFT (or group already participating), Type II NPI form (if applicable), EIN confirmation letter (if applicable), and Email Update Form.
For Nurse Practitioners, include the NP questionnaire; Certified Nurse Midwives must include a collaborative agreement.
Behavioral health outpatient providers must be independently licensed (e.g., psychiatrists, psychologists, LICSW, LMHC, LMFT, LBA); masters-level non-independent clinicians are not credentialed for outpatient professional services.
If a site visit is applicable (new practices or locations), comply with site visit requirements.

ALL of the following

Submit a completed application with all required supporting documents dated within 180 days when specified; incomplete applications will be discontinued and the provider notified and must restart if they wish to reapply.
BCBSRI will issue a decision regarding a new provider's credentialing application no later than 45 calendar days after receipt of a complete credentialing application.
If approved by the Credentialing Committee, the effective date is the day following the Committee approval date and the applicant will be notified within 10 business days.
Providers denied participation or terminated for cause may not reapply for participation consideration within 12 months of the denial/termination date.

ALL of the following

BCBSRI will initiate recredentialing on the 2-year anniversary of the provider's last credentialing/recredentialing date to ensure compliance with NCQA's 3-year recredentialing requirement.
Recredentialing requires confirmation that professional liability insurance, medical license, DEA (if applicable), hospital privileges, and other required information are current in CAQH or on file.

Coding and Liability Requirements

Not applicablemixed

No codes listed

inv-03: Professional liability insurance — per occurrence and aggregate limits

Per-occurrence limit$1,000,000 professional liability insurance per occurrence

Aggregate limit$3,000,000 professional liability insurance aggregate

Carrier requirementInsurance must be with a carrier licensed in the state of practice or approved by BCBSRI

Application Submission and Timelines — What Providers Must Do

Documentation Required

Provider application submission and timelines — highlight required submission (CAQH or dental), required documents, timeframes for decision and notice

Providers must submit a complete credentialing or recredentialing application through BCBSRI’s accepted submission methods (e.g., CAQH ProView or BCBSRI dental application when applicable). A complete application must include all required supporting documents (see items) dated within 180 days of submission when specified. BCBSRI will review completed applications and issue a credentialing decision within 45 calendar days of receipt of a complete new provider application. If approved, the effective date will be the day after Credentialing Committee approval and the provider will be notified within 10 business days. If required components are missing, the application will be discontinued and the provider will be notified; to pursue participation the provider must reapply and submit a new, complete application.

Submit application via CAQH ProView when applicable, or via the BCBSRI provider/dental application portal.
Include the following required documents (all must be current as noted and evidence dated within 180 days where specified): Professional liability insurance declaration (minimum $1,000,000 per occurrence / $3,000,000 aggregate); current state medical license; DEA certificate (if applicable); board certification documentation (if applicable); evidence of after‑hours/24/7 coverage or practice coverage plan (PCPs and as required by specialty); hospital admitting privileges or plan for admitting BCBSRI members; signed BCBSRI Participating Provider Agreement; W‑9; EFT form (with voided check) unless billing under an existing participating group; Type II NPI form if billing under a group NPI; EIN confirmation letter if name/TIN mismatch; email update form.

Application Contents and Behavioral Health Provider Definitions

inv-05: Completed application components and required supporting documents (licenses, DEA, hospital privileges, agreements) with 180-day dating requirement

Acceptable application formsCompleted CAQH or Dental application included with submission

Supporting documents — licensing and credentialsCopy of current medical license and board certification documentation (if applicable) attached to the application

Supporting documents — DEA and hospital privilegesValid, unrestricted DEA certificate if applicable in each state of practice; admitting privileges to at least one contracted hospital or a plan to admit members

Supporting documents — administrative formsSigned current BCBSRI Participating Provider Agreement, W-9 form, EFT form or proof of group participation, Type II NPI and EIN confirmation letter when applicable

180-day dating requirementCompleted application components and supporting documents must be dated within the prior 180 days of the application