The Blue Cross Blue Shield credentialing process for healthcare providers is not just a maze to navigate. It is a deep dive into an ocean where the rules become more obscure as you go. From varying credentialing requirements across states to provisional network participation rules and CAQH profile challenges, everything can act as an impediment to your BCBS credentialing application.
However, that should not stop you from enrolling and credentialing with BCBS. Our detailed guide on BCBS provider credentialing aims to help you effortlessly cross every hurdle and set you on your way to the final approval.
But before we light up the path for you, here is a brief overview of Blue Cross Blue Shield.
Blue Cross Blue Shield – Company Overview
Blue Cross Blue Shield (BCBS) is one of the seven largest health insurance companies, collectively holding 75% of the market share. Originating in 1929 in Dallas, Texas, as the Baylor University Hospital plan, BCBS set the foundation of the modern-day health insurance system. Under the Baylor Plan, hospital administrators were given 21 days of coverage per year for hospitalization if they prepaid 50 cents every month.
Today, nearly 96 years later, BCBS, operating as the Blue Cross Blue Shield Association (BCBSA), is a leading medical insurance company, owning 33 independent, community-based, and locally operated BCBS companies. It provides healthcare coverage to 118 million members (beneficiaries) in 50 states, Washington, D.C., and Puerto Rico. Moreover, over 2 million medical doctors and hospitals have contracts with the BCBS companies.
But did it stop there? NO! Blue Cross Blue Shield Global™, recognized in more than 170 countries, offers medical coverage to people who work, live, and travel internationally. So, if you are thinking about credentialing with BCBS, you are thinking Global!
How to Get Credentialed with BCBS?
When it comes to BCBS credentialing, the state where you practice matters. Why? Because you are required to submit your application to the BCBS company that is licensed to operate in your state. For example, if you are a healthcare provider in California, then you must submit your credentialing application to Blue Shield of California. Similarly, if you are a physician in New Jersey, then your credentials must be submitted to Horizon Blue Cross and Blue Shield of New Jersey for review and in-network enrollment.
As mentioned in the introduction to this blog, BCBS credentialing requirements vary slightly by state. However, being a Dallas-based medical billing company and credentialing specialists, we will focus on the credentialing process set forth by Blue Cross and Blue Shield of Texas (BCBSTX). Hopefully, it will give you a basic idea of the intricacies involved in BCBS provider credentialing.
So let’s start!
Step 1: Review BCBS Credentialing Requirements
The first step is to understand what the company expects of you. In other words, you must carefully review the credentialing requirements for your BCBS company to ensure that you are indeed eligible to be a part of their network.
In the case of BCBSTX, the credentialing requirements for office-based physicians or professional providers are as follows:
- You must be one of the following:
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
- Doctor of Dental Surgery (DDS), oral and maxillofacial surgery
- Licensed Physical Therapist, Occupational Therapist
- Behavioral Health Provider
- Optometrist, Audiologist, Speech and Language Pathologist
- Podiatrist
- Chiropractor
- Acupuncturist
- Physician Assistant, Surgical Assistant, Advanced Practice Nurse, Certified Midwife
- Registered Nurse First Assistant
- Registered Dietician
- You must have completed your residency before being a contracted provider.
- If you are a physician assistant, you must be National Commission on Certification of Physician Assistants certified and maintain certification for continued participation.
- You must provide all the information requested in the TX Initial Credentialing Checklist.
- You must NOT BE an applicant in a training program.
- You must be aware of your provider rights:
- Right to review information submitted for the BCBC credentialing and recredentialing application.
- Right to be notified if erroneous information is discovered during the verification process from any primary source.
- Right to correct incorrect information (within 30 calendar days).
- Right to be informed of your BCBS credentialing application status, upon request.
Step 2: Complete the BCBS Credentialing Application
Once you are sure that you fulfil all the requirements and are ready to start the BCBS credentialing process, log in to your Council for Affordable Quality Healthcare’s (CAQH’s) Provider Data Portal (a free online service) to fill out your application. If you don’t have a CAQH profile, be sure to set up one before filling out the BCBS credentialing application.
Note that only those physicians and other professional providers are exempted from using the CAQH Provider Data Portal database for application submissions who are “participating through delegated credentialing agreements/contracts or are solely practicing in a hospital-based environment”.
BCBSTX allows manual submissions (although not preferred), but for that, the entire packet must be faxed to 972-996-8230 or mailed to:
Blue Cross and Blue Shield of Texas,
Attn: Enterprise Credentialing,
P.O. Box 65067,
Dallas, TX 75265-0267
Step 3: Submit the BCBS Credentialing Application for Review
Remember, you have 45 days to finalize your CAQH application. In case of delays, your BCBS credentialing process will be discontinued.
Once submitted, BCBS will take 8 to 10 calendar days to review your application. You will be notified once your BCBS credentialing application has been reviewed for completeness.
Note that this step involves verifying the submitted information from all primary sources, such as your medical college, medical board, and previous and current employers. BCBSTX uses Verisys® (formerly Aperture) as its Centralized Verification Organization. So, Verisys will independently verify your credentials and send you a notification regarding initial credentialing events.
Step 4: Check the BCBS Credentialing Application Status
While the committee reviews your BCBS credentialing application, verifies your credentials, evaluates your compliance, and either approves or rejects your credentialing request, it is your job to follow up on its status. The BCBS credentialing application status can be checked by referring to the Case and Credentialing Status Checkers.
The complete credentialing process can take between 45 and 90 days. So, be mindful of that as you follow up on the application status. BCBS will send you a written response once the final determination is reached on your credentialing application.
BCBS Provider Credentialing Application Requirements
Based on BCBSTX’s Initial Credentialing Checklist, you must provide the following information and supporting documents to complete your BCBS credentialing application:
- Personal information
- Type of profession
- Name
- General information (gender, DOB, SSN, city/state/country of birth)
- Education
- Graduate/professional school(s)
- Training list, all training programs attended relative to the practicing specialty
- Licenses and certificates
- Professional IDs (state and DEA)
- Professional and/or specialty information
- Primary specialty
- Secondary specialty (if applicable)
- Board certification information
- Work history
- Work history (must have five years with no gaps greater than six months)
- Gaps in professional/work history (explanation of work history gaps)
- Hospital affiliations
- Admitting arrangements (hospitalist, covering physician)/Hospital Coverage Letter
- Hospital privileges.
- Professional liability insurance coverage
- Insurance carrier
- Policy number
- Effective date
- Expiration date
- Occurrence and aggregate amount
(Note: Since 2021, the minimum requirements have been reduced from $200,000 per occurrence/$600,000 aggregate to $100,000 per occurrence/$300,000 aggregate for Texas providers)
- Practice location information
- Primary location information (location, phone, fax, e-mail, and TIN)
- Office manager or credentialing contact
- Answer to disclosure questions
- All questions must be answered, and any question answered ‘YES’ must have an explanation
- Authorizations, attestations, and releases
- BCBSTX in the entity box
- Initials and date
- Signature (cannot be stamped)
- Printed name
- Last 4 digits of SSN or NPI
- Date
- Attachments
- DEA (if applicable)
- Board certification information (if applicable)
- Any supplemental forms with an explanation to disclosure questions answered “YES”
- Current certificate of insurance
Challenges in Getting Credentialed with BCBS
As can be seen from the several steps and requirements above, credentialing is a complex, intricate, and time-consuming process. Many who have travelled this path alone met obstacles that either slowed down their pace or forced them to turn back and return with expert guides.
If you have decided to get credentialed with BCBS, understand that you, too, are likely to encounter some of the challenges discussed below.
Navigating State-Specific BCBS Credentialing Requirements
With its nationwide footprint and presence in Puerto Rico, BCBS’s credentialing requirements are tailored to each state’s specific laws and regulations. While the basic process remains the same (creating the CAQH profile, completing the application form, and attaching the required documents), there might be slight variations, such as the provisional network participation rules and the verification protocols.
This can confuse healthcare providers, especially those who operate/practice in more than one U.S. state, further delaying the BCBS credentialing process and healthcare delivery.
Ensuring Security During Documentation Management
When completing your BCBS credentialing application, you are required to provide your personal and sensitive information, including your name and address, date of birth, social security number, and tax information. If this information gets into the wrong hands, it can be used to harm you, such as to steal your identity and perform financial transactions on your behalf.
Even though CAQH ProView is a secure platform, other Cloud-based document management tools, like Google Drive and Dropbox, are routinely hacked. So, completing and submitting a BCBS credentialing application with optimal security is easier said than done.
A Lack of Communication and Clarity
Often, the rules and requirements for provider credentialing are not as clearly spelled out as one would like them to be. Obscure guidelines, confusing instructions, missing details, or misleading information can unnecessarily complicate the process. And what really adds to applicants’ misery is when they are unable to get a direct answer from the insurance company’s representative. Some providers applying for BCBS credentialing have met the same fate.
Information Discrepancies in BCBS Credentialing
However, unclear, missing, or inconsistent information is not always a problem from the payer’s end. Providers can unknowingly disrupt or delay BCBS credentialing, too, when they submit inconsistent information across applications or fail to update their older CAQH profiles. They forget that CAQH ProView is a centralized online database that is accessible to multiple insurance payers, not just BCBS. So, what you state in there must be accurate, updated, and standardized.
Delays in BCBS Provider Credentialing
BCBS credentialing can take as few as 45 days and as many as 90 days, depending on how comprehensive your application is and how long it takes for the committee to verify your credentials. Note that you cannot render care to BCBS beneficiaries (policyholders) until you are credentialed, have enrolled in their network, and have signed a contract.
However, you may be granted a provisional network participation status if you:
- Have a valid BCBS Provider Record ID for claim payment.
- Submit a signed copy of the current BCBS contract/agreement.
- Provide a valid state licence in good standing with that state’s licensing boards.
- Send a receipt of the completed CAQH Provider Data Portal application with “global” or “plan-specific” authorization to BCBS.
Best Practices for BCBS Insurance Credentialing
Now that you are aware of some of the biggest pitfalls that can derail your BCBS provider credentialing, let’s discuss a few best practices that can help you successfully navigate past them.
Maintain Comprehensive Records
First and foremost, you must keep a detailed record of your personal, educational, and professional data, including licenses and certifications. Moreover, this record must be properly organized to mitigate lapses. We recommend organizing the information chronologically in separate folders for each category.
It will ensure that all the required information and supporting documents are readily available as you progress through your BCBS credentialing application.
Update Your CAQH Profile Regularly
The next step of ‘staying organized’ involves regular updates of your CAQH profile. Don’t wait until it is time to submit your credentialing or recredentialing application. As soon as an update is required, for example, a new certification, a job switch, or a change in referral, edit your profile.
Start the Recredentialing Process 6 Months in Advance
Typically, BCBS providers are required to recredential every 3 years. This ensures the continuity of a trusted healthcare system. We recommend that you prepare the paperwork and a draft of your recredentialing application 6 months ahead of schedule to prevent delays and disruptions in healthcare delivery.
Diligently Follow Up on BCBS Credentialing Application Status
Don’t wait around for that notice to appear. Yes, BCBS will notify you of its decision to approve or reject your credentialing application, but that does not mean that you should let the days slip by. We suggest that you start tracking your BCBS credentialing application status 40 days after submission using the Credentialing Status Checker (for BCBSTX). Simply enter your license number or NPI number to get started.
Partner with a Credentialing Company for Error-Free BCBS Credentialing
Why not let the experts handle credentialing complexities? If you are tired of going back and forth with your credentialing requests, then it is time to pass that load to specialists and take some well-deserved rest. Medical credentialing companies offer tailored services on a flat fee per application or a monthly rate. The team’s deep understanding of BCBS’s state-specific credentialing requirements can save you hours of work and stress, ensuring that complete and compliant applications are submitted on your behalf.
Fast-Track your BCBS Credentialing with MediBillMD
Provider credentialing is a stringent process that ensures all healthcare providers willing to join the Blue Cross Blue Shield network meet the professional standards required to deliver quality care to BCBS beneficiaries. It involves a comprehensive review and validation of the applicant’s professional qualifications, including any history of malpractice, to uphold patient safety and maintain the integrity of the healthcare system.
If you want to instill confidence in the medical care you provide and join Blue Cross Blue Shield’s wide network of healthcare practices and professionals, first, consider credentialing with BCBS. Can’t handle the time-consuming process on your own? Don’t worry, MediBillMD’s insurance credentialing services are here to help. Our credentialing specialists know how to take out the ‘TEDIOUS’ from ‘Blue Cross Blue Shield credentialing’. They can not only streamline the paperwork but also fast-track the process, so you don’t have to delay caring for your patients.
