Credentialing Process for Blue Cross Blue Shield Providers 

Introduction: Why BCBS Credentialing Matters 

Blue Cross Blue Shield (BCBS) is an association of health insurance organizations that is franchised and is one of the best networks of health insurance. It boasts a membership of over 115 million across all the states. In the case of healthcare providers, joining the BCBS network is not a mere choice but a strategic decision. In-network practitioners usually choose BCBS patients to keep the out-of-pocket expenses low. For providers, joining the BCBS network can help build patient trust, attract more patients, and generate a steady income. 

Nevertheless, a patient with insurance provided by BCBS will not be able to access services offered before you are credentialed to be an in-network provider. This is meant to keep all doctors, nurse practitioners, therapists, and clinics in line with the requirements of BCBS quality and safety. Its components are license checks, education checks, insurance checks, and professional history checks. It might be overwhelming because of the paperwork, but it is a necessary part of growth in practice and building a better reputation in the healthcare field. 

Get overwhelmed with Blue Cross Blue Shield credentialing? Let our team assist you. 

Who Can Apply for BCBS Credentialing? 

Healthcare providers of various types can undergo the credentialing process. The candidates may be family physicians, surgeons, or professionals. Nurse practitioners and physician assistants are also eligible to practice, and this also involves behavioral health professionals like psychologists, counselors, and psychiatrists. Chiropractors, physical therapists, occupational therapists, and speech-language pathologists are also welcome to join the network on condition of meeting the requirements. Depending on the state and the type of plan, dentists and oral surgeons can have BCBS credentialing. 

Besides the type of provider, BCBS defines certain professional needs. Applicants must be licensed in the state with an active and unlimited license, maintain sufficient malpractice insurance with specified coverage limits, have an acceptable professional or personal background, and hold the necessary education and board certifications where required. A background check is also necessary. It is important to stay current on the CAQH profile, as BCBS often accesses data through the profile via CAQH ProView. To put it in simpler terms, you can become a part of the BCBS network as a qualified medical worker, provided that you have the needed documents at hand. 

The Process of BCBS Credentialing 

In spite of the fact that in each state, there is a BCBS branch, the general process in the entire industry is not too different. The first step to becoming a provider is to file a provider application request at the Blue Cross Blue Shield site in your state. The following information is needed to complete this request: your specialty, place of practice, tax identification number, and NPI number. BCBS will post you the complete application in case its network in your area can accommodate new providers. 

The next step is to share your profile with the CAQH. CAQH ProView is a one-database system in which providers store their professional information. To enroll in BCBS, make sure that your CAQH account is up to date. This entails updating personal information, professional history, work experience, and practice details, and uploading such documents as your state license, malpractice insurance certificate, DEA certificate, and CV. You must also make BCBS able to access your CAQH profile. A partial or unfinished CAQH account can be a reason for a delay in the credentialing process. 

You will also be required to submit other documents to BCBS once your CAQH profile has been updated. These generally involve your W-9 form, malpractice claims history, evidence of board certification, and, in certain situations, evidence of hospital privileges. Every state needs various supporting documents, but accuracy and completeness are always important. The unavailability or wrong date of documents may slow your application. 

After the documents are received, the primary source verification process of BCBS starts. This is the most important step as BCBS will get in touch with schools, licensing boards, and previous employers to confirm your performance history and credentials. This is to get all the information you have given from verified and specific origin. The application is sent to the credentialing committee after the verification. This is a health practitioner and official committee that examines your credentials, experience, and fitness. Once they determine that everything complies with BCBS standards, the committee may then approve your contract. 

Contracting and joining the network is the final step. BCBS will mail out a participation agreement to you. The contract will specify your reimbursement rates, billing, and in-network provider requirements. The signature and the rest of the contract will make you an official member of the BCBS network and will permit you to have patients covered by BCBS. 

Documents You Will Need 

You can have your documents ready ahead of time to avoid frequent unneeded delays. The documents that are typically needed are the copies of your state medical license, DEA certificate in case you are prescribing medication, malpractice insurance certificate, a demonstration of educational accreditation and board certifications, and your curriculum vitae with a comprehensive history of work. Your NPI number will also be required, as well as, in certain circumstances, evidence of hospital privileges. Providers should make sure that they have up-to-date and signed documents. A simple failure, such as an expired malpractice certificate, can extend the process of the application by weeks. 

How Long Does the BCBS Credentialing Process Take? 

The BCBS timeline of credentialing is usually between 60 and 120 days. This can be done shorter (when all is in order) or longer, depending on the specialty, the location, and the responsiveness of the provider. Typically, the duration of application review is two to four weeks, verification is four to eight weeks, the credentialing committee decision is two to four weeks, and contracting is one to two weeks. 

Most delays are a result of incomplete CAQH profiles, incompleteness of documents, or delays on the part of the licensing boards and schools. When providers remain active, maintain CAQH updated, and have a fast response to appeals, their application may proceed along a much smoother path with minimal or no avoidable delays. 

Challenges Providers Often Face 

BCBS credentialing is another problem for most providers. Network saturation is the most popular. Another frequent problem is incomplete or outdated CAQH profiles when BCBS in the area does not accept new providers because of the adequate coverage already in place, and they cannot be verified. There is also the slow response of licensing boards or educational institutions, which further pushes up deadlines.  

Even the simplest mistakes in application forms, like a typing mistake in an address or a date mismatch, can cause major delays. Another barrier that is likely to arise is malpractice insurance in case the minimum standards demanded by BCBS are not achieved. 

How to Avoid Delays 

It is always good to be proactive and organized, since this will prevent delays. Providers are encouraged to maintain an up-to-date work history and documents in their profile as a way of optimizing the CAQH.  

The malpractice insurance and state licenses should be renewed prior to their expiration date, and the scans can be uploaded to CAQH and sent to BCBS.  

In turn, responding quickly to the requests of BCBS contributes to an efficient process. Having tracked your application and regular checkups can be the difference between a delay and the discovery of problems.  

This is one of the processes that many providers find useful to have the assistance of credentialing experts to deal with, to save time and reduce errors. 

Final Thoughts 

Credentialing by Blue Cross Blue Shield does not only entail paperwork. It is all about demonstrating your dedication to high-level care, safety, and professionalism. Although it is time-consuming and inaccurate, the gains are substantial. When providers enter the BCBS network, they are not only exposed to insurance reimbursements, but they also increase their reputation with the medical fraternity. The trick to success is to get ready in advance, update your CAQH profile, and be organized during the application process. 

Credex Healthcare experts can help you get started in your Blue Cross Blue Shield credentialing process. 

FAQs 

How long is the BCBS credentialing process time? 

Average time is around 60-120 days, with consideration of your specialty area, where it is located, and your speed in submitting the papers. 

Is BCBS CAQH mandatory? 

Most of the BCBS plans apply the CAQH ProView in order to report and certify provider data. 

Am I pre-qualified as a group practice? 

BCBS credentialing can be pursued by individual providers and by group practices. 

What will be the action in case my application is rejected? 

Denial of the application could be reversed in case you rectify the shortcomings that led to the denial.