CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Provider Credentialing and Recredentialing Policy

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Defines BCBSRI requirements and processes for initial credentialing and periodic recredentialing of participating healthcare providers and the documentation required to establish and maintain network participation.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProvider Credentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 18, 2023

Last ReviewMay 15, 2024

Next Review DateMay 15, 2024

Key ActionProviders are notified every 15 days with status updates and complete applications are acknowledged within 5 business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45 daysdecision timeframe (new provider)

180 daysmax age of supporting docs

1M / 3Mliability insurance (occ/agg USD)

2 yearsrecredentialing initiation

12 monthsreapply after denial

Credentialing and Recredentialing Criteria

Required elements and operational criteria for a complete credentialing or recredentialing application per OHIC and BCBSRI rules.

Provider demographics: name and current mailing address; documentation must be dated no more than 180 days prior to submission.

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

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

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

Federal DEA certificate: valid, unrestricted DEA certificate required if applicable to the applicant's specialty and in each state in which the provider practices.

Education/Training: provider will be reviewed at the highest level of education completed at time of submission; exception for resident graduates for transitional status until graduation.

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

History disclosures: disclosure of any revocation, suspension, probationary status or other disciplinary action regarding licenses, and history of professional liability claims, including settlements or judgments.

Administrative documents: signed BCBSRI Participating Provider Agreement, W-9 form, Type II NPI (if applicable), EIN confirmation (if name/TIN mismatch), Email Update Form, and EFT form (unless billing via an existing participating group).

Practice requirements: PCPs must provide after-hours coverage; 24/7 coverage may be required depending on provider type; PCP office hours minimum 20 hours/week or three days/week with appropriate coverage arrangements.

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

Application timing and notifications: applicants are notified of status every 15 days; BCBSRI will notify the applicant within 5 business days once an application is deemed complete; credentialing decision for new providers is made within 45 calendar days of receipt of a complete application; effective date is the day after Credentialing Committee approval and written notice is sent within 10 business days if approved; incomplete applications will be discontinued and require restarting the process.

Recredentialing schedule and requirements: BCBSRI initiates recredentialing on the 2-year anniversary of the last credentialing/recredentialing date to meet NCQA 3-year requirement; providers must keep CAQH information current and provide the same required elements as initial credentialing.

Denial/reapplication restriction: providers denied or terminated for cause may not reapply for 12 months from the date of denial or termination.

Application Communications and Timing

Documentation Required

Application status notifications and timing

Upon receipt of an application, BCBSRI will notify the provider of their application status 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 approved by the Committee, the effective date is the day following Committee approval and the applicant will be sent notice within 10 business days. If required components are missing, the application will be discontinued and the provider will be notified; reapplication is required to re-enter the process.

Status updates provided every 15 days after application receipt.
Acknowledgement of a complete application within 5 business days.
If approved, notice sent within 10 business days and effective date is day after Committee approval.
Incomplete applications will be discontinued and require restarting the process to reapply.

Completed Application

Completed application — required fields and documents

Provider demographicsName and current mailing address; must be dated within 180 days of application submission

Professional liability insuranceMinimum $1,000,000 each occurrence and $3,000,000 aggregate with an insurer licensed in state of practice or approved by BCBSRI

Medical license and DEA certificateCopy of current medical license; valid, unrestricted DEA certificate if applicable to specialty

Board certification and hospital privilegesDocumentation of board certification if applicable; admitting privileges to at least one contracted hospital or documented plan for admitting BCBSRI members

Administrative/provider agreement documentsSigned BCBSRI Participating Provider Agreement, W-9, Type II NPI (if applicable), EIN confirmation if TIN/name mismatch, and EFT form for payment setup

Timeliness and process acknowledgmentApplication acknowledged as complete within 5 business days; credentialing decision for new providers issued within 45 calendar days of receipt of a complete application; providers receive status updates every 15 days

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProvider Credentialing and Recredentialing Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 18, 2023

Last ReviewMay 15, 2024

Next Review DateMay 15, 2024

Key ActionProviders are notified every 15 days with status updates and complete applications are acknowledged within 5 business days.

SourceLink

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