Credentialing



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Credentialing is the process by which BCBSIL reviews and validates the professional qualifications of physicians and certain other providers who apply for participation in the BCBSIL HMO, PPO and Blue Choice PPOSM networks, ensuring they meet our professional standards.

 

Provider Rights: Applicants applying or reapplying for participation or continued participation in the Health Plan networks have the right to be informed of the following:

  • Right to review information submitted on or with their credentialing and recredentialing application;
  • Right to correct erroneous information;
  • Right to be informed of the status of their credentialing or recredentialing application, upon request.

Applicants should direct all requests to their Provider Network Consultant. The Enterprise Credentialing Department will notify the applicant in writing if erroneous information is discovered during the verification process from any primary source. Applicants will be given sufficient time to correct erroneous information and resubmit to the Enterprise Credentialing Department. It will be the applicant’s responsibility to work directly with the reporting entity to correct the erroneous information.




New Credentialing Process

CAQH* will collect the data required for our credentialing and recredentialing process.

 

CAQH uses a Universal Provider Datasource (UPD)® form to electronically collect the data. The UPD online credentialing application process supports our administrative simplification and paper reduction efforts. This solution also supports quality initiatives and helps to ensure the accuracy and integrity of our provider database. Providers may utilize the UPD database at no cost.

 

Network Eligible Providers
The following provider types must complete the credentialing process, and be recredentialed every three years:

  • Professional Provider Types: MD, DO, PSYD, DC, CNM, LCSW, LCPC, LMFT,  DPM, PA, APN and CNP. 
  • Institutional Providers: Hospitals and Ancillary

View a listing of the specialists for each network 

 

Additional Resources  
CAQH Contact Information Help Desk   888-599-1771
Online Application System URL HTTPS://UPD.CAQH.ORG/OAS 
Help Desk Email Address caqh.updhelp@acsgs.com
Help Desk Hours 6 a.m. - 8 p.m., CT, Monday through Thursday,
6 a.m. - 6 p.m., CT, Friday
Fax Supporting Documentation to: 866-293-0414

Frequently Asked Questions 

 

CAQH Provider and Practice Administrator Quick Reference Guide 


*The Council for Affordable Quality Healthcare, Inc. (CAQH) is a not-for-profit collaborative alliance of the nation’s leading health plans and networks. The mission of CAQH is to improve health care access and quality for patients and reduce administrative requirements for physicians and other health care providers and their office staffs.
CAQH is solely responsible for its products and services, including the Universal Provider Datasource.


Activating your UPD Registration

Blue Choice PPO, HMO and PPO network providers must have a CAQH Provider ID to register and begin the credentialing process.

 

First time users: (If you are not registered with CAQH and are a first-time user)

  1. When you apply for network participation, BCBSIL will add your name to its roster with CAQH.
  2. CAQH will mail you a Welcome kit with registration instructions, along with your personal CAQH Provider ID, allowing you to obtain immediate access to the UPD database via the Internet.
  3. When you receive your CAQH Provider ID, go to the CAQH website  to register.
  4. After successfully authenticating key information, you will be able to create your own user name and unique password to begin using the system.

Once registration is completed, you may use your user name and password to log in at any time.

 

Existing users:

  1. If you have already registered your CAQH Provider ID and completed your UPD online application, ensure that you have authorized BCBSIL to access your credentialing information. This can be completed in four easy steps, as noted below. (If you have chosen "global authorization", then BCBSIL will already have access to your data).
  2. To authorize BCBSIL to access your data:
    • Go to HTTPS://UPD.CAQH.ORG/OAS  and enter your username and password
    • Click the Authorize tab (located under the CAQH logo)
    • Scroll down and check the box beside BCBSIL, or you may select "global authorization".
    • Click Save to submit your changes.

Completing the Application Process
The UPD standardized application is a single, standard online form that meets the needs of all participating health care organizations. When completing the application, you will indicate which participating health plans and health care organizations you authorize to access your application data. All provider data you submit through UPD service is maintained by CAQH in a secure, state-of-the-art data center.

 

Checklist of documents that may be required to complete the online application:

  • Previously completed credentialing application (for reference)
  • List of previous and current practice locations
  • Various identification numbers (UPIN, NPI, Medicare, Medicaid,etc)
  • State medical license(s)
  • Curriculum Vitae
  • Drug Enforcement Administration (DEA) Certificate
  • Controlled and Dangerous Substances (CDS) Certificate
  • IRS Form W-9(s)
  • Malpractice insurance face sheet
  • Summary of any pending or settled malpractice cases

When you are ready to begin entering your data, log in to UPD  with your user name and password.

After completing the online application, you will also be asked to:

 

  • Authorize access to your information
    Check the organizations that you authorize to share your information or provide a global authorization.
  • Verify your data entry/Attest 
    Review the summary of your data for accuracy and completeness, make any necessary changes.
  • Submit supporting documents 
    Fax the documents required to complete your application to CAQH at 866-293-0414. Supporting documents include:
    • State medical license(s)
    • Drug Enforcement Administration (DEA) Certificate
    • Controlled and Dangerous Substances (DPS) Certificate
    • Malpractice insurance face sheet
    • Summary of any pending or settled malpractice case(s) - if within the past 10 years
    • Curriculum Vitae
    • Signed Attestation (page 18 of online application – print and sign)

If you have any questions on accessing the UPD database,  you may contact the CAQH Help Desk at 888-599-1771 for assistance.

 

NOTE: BCBSIL may contact you to supplement, clarify, or confirm certain responses on your application. Therefore, you may be required to submit additional documentation in some situations, in addition to the information you submit through the UPD database.

 

Visit the CAQH website  for more information about the UPD database and the application process. Or you can view the CAQH Provider Credentialing Application  now.

 

HMO Medical Group/IPA Practitioners
If you are a practitioner affiliated with one of our HMO-contracted Medical Groups/IPAs, BCBSIL must receive the following documents after you complete the CAQH credentialing application.

  • Signed HMO written service agreement with the Medical Group/IPA,
  • HMO Credentialing Application Short Form

Your application will not be considered complete without these documents.

 

View a list of Frequently Asked Questions  regarding the CAQH process for HMO Medical Groups/IPAs and HMO Providers.


Keeping your information current is your responsibility, and you must do so with BCBSIL and CAQH.

 

CAQH will send you automatic reminders to review and attest to the accuracy of your data. Use the UPD database to report any changes to your practice, in accordance with the time frames outlined in the State of Illinois Health Care Professional Credentials Data Collection Act, as follows:

  1. Within five business days for state health care professional license revocation, federal drug enforcement agency license revocation, Medicare or Medicaid sanctions, revocation of hospital privileges, any lapse in professional liability coverage required by a health care entity, health care plan or hospital, or conviction of a felony.
  2. Within 45 days from the date you knew of the change, for any other information provided on your credentialing application, i.e., practice address, hospital affiliation, etc.

You must enter your changes into the UPD database for us to access during the credentialing and recredentialing process. Only the health plans that participate in the UPD database and that you have authorized access will receive any changes.

 

BCBSIL Provider File Updates

It is important that you also inform BCBSIL of changes to your practice. If you are a participating provider with BCBSIL, you may request most changes online by using one of our electronic change request forms.

 

Go to the Request an Information Change page for information on the process to submit a provider change request.


The process for recredentialing is identical to that for credentialing, and is consistent with NCQA and State of Illinois requirements. If your credentialing application is not available to BCBSIL because you have not completed the UPD credentialing process, you will be added to our roster and CAQH will send you a Welcome Kit that includes your CAQH Provider ID so that you can complete the UPD credentialing process. This will help you continue to conform to the requirements of your network contract.

 

Note: If you need more information go to Getting Started with CAQH.

 

CAQH requires you to review and attest to your data once every six months. At the time you are scheduled for recredentialing, BCBSIL will send your name to CAQH to determine if you have already completed the UPD credentialing process. If so, we will be able to obtain current information from the UPD database and complete the recredentialing process without having to contact you.

 

The State of Illinois recredentialing cycle requires health care entities to obtain data on physicians according to an established single cycle, which is on an anniversary basis and is performed only once within a three-year period. The state selected the last digit of the physician's social security number to create the single cycle. The cycle for 2012 through 2017 is below.

 

Year 2012 2013 2014 2015 2016 2017
Month Notify Notify Notify Notify Notify Notify

January

0's 4's 8's 0's 4's 8's

February

           

March

           

April

1's 5's 9's 1's 5's 9's

May

           

June

           

July

2's 6's Open 2's 6's Open

August

    Open     Open

September

    Open     Open

October

3's 7's Open 3's 7's Open

November

    Open     Open

December

    Open     Open


BCBSIL applies a single credentialing process so that a provider is credentialed once and may then apply for any managed care network that requires credentialing prior to participation.

 

A monthly report of credentialed and appointed providers is posted here to provide notification of the effective date with Blue Choice PPO, PPO and the HMO products (HMO Illinois and BlueAdvantage HMO). For details, select a report from the list below.

  • The Blue Choice PPO product report  lists providers in alphabetical order and includes the effective date of their appointment/reappointment and contracting group name.
  • The HMO product report  is sorted by HMO Medical Group/IPA affiliation and lists the effective date of each practitioner's appointment/reappointment date. This report includes those providers appointed/reappointed for both the HMO Illinois and BlueAdvantage HMO products.
  • The PPO product report  lists providers in alphabetical order and includes the effective date of their appointment/reappointment and contracting group name.

The report includes information for providers who complete the credentialing process after Jan. 1, 2004. The data is updated weekly.