Provider Credentialing FAQs
Should I go through the provider credentialing process or provider contracting upon initial contact with BlueChoice HealthPlan? You should go through the credentialing process first if you want to be in network. Find the forms you need to become part of the BlueChoice® network on our website. You can contact Provider Enrollment at email@example.com to determine what documents you need if you are not familiar with the credentialing paperwork. This will prevent you from submitting duplicate documents or unnecessary paperwork.
When does the provider effective date begin – upon the signature date of the provider contract or upon completion of the provider credentialing review date? The effective date for networks begins upon completion of the contract review. We base the BlueChoice effective date (date we add the provider to the file) on the signature date on the provider’s application.
What are the differences between individual credentialing and group credentialing? How does this impact a non-participating physician in a participating group? The Provider Enrollment department only handles the individual network credentialing process. Our Provider Contracting area negotiates group contracts for BlueChoice networks. You should contact Provider.Directory@bcbssc.com for clarification about group credentialing.
If I am a mental health provider, should I go through the credentialing process for both BlueChoice and CBA? You will not need to complete the credentialing process for BlueChoice. Credentialing for mental health practitioners is coordinated through CBA and covers the networks for the BlueChoice network. CBA is a separate company that admibisters mental health and substance abuse benefits on behalf of BlueChoice.
How long does the credentialing process take once I submit all required documentation? Why do I have to supply the date I submitted the application to find out my credentialing status? The 90-day review period begins after we receive all required documentation. If an application is missing information or if the application is incomplete, we pend the application and the Provider Enrollment department will request the information from you. Once we receive the information, we send the application to review.
Whom should I contact if I have a question about the status of my provider credentialing application? For BlueChoice provider credentialing questions, please email firstname.lastname@example.org. You can email CBA at email@example.com for questions about mental health provider credentialing.
What provider credentialing form should I use when I have sold the practice to a new physician owner? You should submit the Application for Group/Clinic/Institution to file claims or change Employer Identification Number (EIN). You can find this form on the Update Provider Information page of our website.
What is the process if I am already credentialed and am affiliated with a facility and want to be affiliated with another separate facility? What documentation do you require? You will need to submit the Request to Add Practitioner Affiliation form, the Authorization for Clinic/Group to Bill for Services and the Appendix D and Hold Harmless forms if the group participates with BlueChoice.
Am I required to be accredited with a professional association of my specialty (ex: American College of Radiology)? No, this is not a requirement for our provider credentialing process.
Does BlueChoice use a separate vendor for credentialing (ex: Council for Affordable Quality Healthcare)? BlueChoice does not use any vendor for provider credentialing enrollment or updates. We use our own credentialing department for provider verifications to meet the National Committee for Quality Assurance (NCQA) credentialing standards.
How long is the credentialing process? Provider credentialing has a 90-day review period to process applications. It may be prolonged, however, based on the completeness of the application. If we require additional information, this will extend the credentialing process.
If a physician is licensed and affiliated with a participating practice but not yet credentialed with BlueChoice, can the physician see patients? The physician can see patients. Physicians should not, however, begin filing claims to BlueChoice until they have confirmation that we accepted their credentials.
How often is recredentialing required? Providers go through the recredentialing process every three years. Per the Center for Medicare and Medicaid Services (CMS) mandate, however, you may hear from your provider advocate to verify that your practice and physician information is up to date on an annual basis. You should respond to these requests to ensure your information is current and accurate.
Can I be credentialed if I am missing South Carolina licensure? No. You must have South Carolina licensure to be credentialed with BlueChoice.
How far in advance of a physician signing with our practice should I submit the application to BlueChoice? As soon as a provider knows he or she will require credentialing services — such as a new provider or new location — the better it is to notify us at that time. We are able to give a future date for an application received. For example, a provider can start the credentialing process now for a provider adding a new location months later.
Is the facility or the physician notified when it is time for re-credentialing? The facility never receives a letter about a physician that is due to be re-credentialed. We send re-credentialing letters to physicians. If a facility has a designated department or contact person that handles credentialing, we send the notification there. If a credentialing vendor is designated (ex. EmCare) our credentialing area will contact the vendor. If the proper contacts are not receiving these letters, please update your contact information with us.
When a provider leaves a practice, do BlueCross and BlueChoice note the separation date as the practitioners' last day of employment or the date the application was received? Our concern is there are claims pending they will be denied. We terminate a provider one day beyond the required (requested) termination date. Any claims submitted for dates of service prior to the provider leaving will be processed for payment.
Are nurse practitioners (NPs) also required to complete section III.1 of the credentialing application (Education/Training/Hospital Privileges)? Yes, NPs should complete section III, parts 1 and 2. Part 3 is not applicable to NPs.
Do BlueCross and BlueChoice recognize physicians working under Locum Tenen? We permit practitioners to work in this capacity for three months or less. The provider group must take responsibility to be sure the practitioner who is under Locum Tenen has the appropriate credentials/experience, etc. to perform the procedures assigned to him. If the practitioner will be working with the practice for more than three months, then provider credentialing needs to affiliate, credential, etc. as we would a provider joining that practice.