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Empire BCBS Credentialing Challenges

Are you updated with the Empire BCBS credentialing regulations, as on December, 2015 ? If you are thinking to move to a group, you should better check this out.

As a doctor or a medical practice staff it’s not easy to twist the arm of payer, particularly when it comes to our local BCBS. Outdated manuals which lack critical information create a winning situation for the payer.  You cannot be sure about the billing procedures when it comes to an individual provider and a group practitioner. Do you think it’s all the same?

A very common issue an individual provider faces: Transitioning to a Group

If you are an individual provider and already credentialed with BCBS under your NPI, do you think you need to get re-credentialed as a group provider? Is it possible that Empire BCBS considers it as a provider update? The most important question which haunts is the in-network. Suppose if the group provider/owner is in network do you think all the providers under it can be considered the same?

Should you consider all parts of the state to work similar?

It is not necessary that all parts of the state functions and adhere to one rule. When it comes to BCBS Utica, each individual practitioner needs to be credentialed.  Do ask your new providers who step into your group to contact the Rep and signup a new contract to get a new NPI.  It’s not possible for a new doctor to step in to group and start billing insurances without getting credentialed.  He cannot be considered in-network just because the group is in-network. Each and every provider has to get credentialed on their own.

Do get rid of outdated information! BCBS Anthem’s December 2015 updated checklist for Re-credentialing:

  1. Submission of complete re-credentialing application and required attachments that must not contain intentional misrepresentations;
  2. Re-credentialing application signed date within one hundred eighty (180) calendar days of the date of submission to the CC for a vote;
  3. Primary source verifications within acceptable timeframes of the date of submission to the CC for a vote, as deemed by appropriate accrediting agencies;
  4. No evidence of potential material omission(s) on re-credentialing application;
  5. Current, valid, unrestricted license to practice in each state in which the practitioner provides care to Covered Individuals;
  6. *No current license probation;
  7. *License is unencumbered;
  8. No new history of licensing board reprimand since prior credentialing review;
  9. *No current federal or state sanction and no new (since prior credentialing review) history of federal or state sanctions (per OIG and OPM Reports, state sanction/exclusion listings, or on NPDB report);
  10. Current DEA, CDS Certificate and/or state controlled substance certification without new (since prior credentialing review) history of or current restrictions;
  11. No current hospital membership or privilege restrictions and no new (since prior credentialing review) history of hospital membership or privilege restrictions; OR for practitioners in a specialty defined as requiring hospital privileges who practice solely in the outpatient setting there exists a defined referral relationship with a Network practitioner of similar specialty at a Network HDO who provides inpatient care to Covered Individuals needing hospitalization;
  12. No new (since previous credentialing review) history of or current use of illegal drugs or alcoholism;
  13. No impairment or other condition which would negatively impact the ability to perform the essential functions in their professional field;
  14. No new (since previous credentialing review) history of criminal/felony convictions, including a plea of no contest;
  15. Malpractice case history reviewed since the last CC review. If no new cases are identified since last review, malpractice history will be reviewed as meeting criteria. If new malpractice history is present, then a minimum of last five (5) years of malpractice history is evaluated and criteria consistent with initial credentialing is used.
  16. No new (since previous credentialing review) involuntary terminations from an HMO or PPO;
  17. No new (since previous credentialing review) “yes” answers on attestation/disclosure questions with exceptions of the following:
  18. Investment or business interest in ancillary services, equipment or supplies;
  19. Voluntary resignation from a hospital or organization related to practice relocation or facility utilization;
  20. Voluntary surrender of state license related to relocation or nonuse of said license;
  21. An NPDB report of a malpractice settlement or any report of a malpractice settlement that does not meet the threshold criteria;
  22. Nonrenewal of malpractice coverage or change in malpractice carrier related to changes in the carrier’s business practices (no longer offering coverage in a state or no longer in business);
  23. Previous failure of a certification exam by a practitioner who is currently board certified or who remains in the five (5) year post residency training window;
  24. Actions taken by a hospital against a practitioner’s privileges related solely to the failure to complete medical records in a timely fashion;
  25. History of a licensing board, hospital or other professional entity investigation that was closed without any action or sanction.
  26. No QI data or other performance data including complaints above the set threshold.
  27. Recredentialed at least every three (3) years to assess the practitioner’s continued compliance with Empire BCBS credentialing standards.

*Empire states that it will discover these results for the current network providers with through ongoing sanction monitoring. The CC will be individually reviewing the network providers with these results.

You can download your copy of the latest Empire BCBS credentialing provider manual for more information.

Download Provider Manual here

Note: The above checklist is posted as released by Empire BCBS. We are not a partner of Anthem BCBS or a member. All we want is that correct and updated information reaches the needy healthcare professionals.

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