Credentialing

Credentialing Process

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

CAQH uses the ProView^TM credentialing system to electronically collect the data. The ProView 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 ProView 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, PHD, AUD, BCBA, OD, DC, CNM, DPM, LCSW, LCPC, LMFT, PA, APN, APRN, ANP, CNP, CNS, RD, LAC and DN.
• Institutional Providers: Hospitals and Ancillary

Network Eligible Specialists list

CAQH Tool Verifies Credentialing Information

We’re working with VERISYS to verify your credentialing data after you enter it into ProView. VERISYS may contact you on behalf of BCBSIL and request that you:

• Re-attest to your data’s accuracy, or
• Complete your credentialing application by entering or attaching missing information in CAQH ProView

Please respond as soon as possible to help complete the credentialing process. You’ll receive written notification of your status when the credentialing process is completed.

Reminder: Verify Separately for the Provider Directory

Entering and attesting to data in CAQH ProView for the credentialing process doesn’t verify the information that’s needed for the federal Consolidated Appropriations Act (CAA). You must verify your provider directory information separately to meet CAA requirements.

• The CAA requires that certain directory information be verified every 90 days, even if your data hasn’t changed since you last verified it.
• We recommend that professional providers use the Availity^® Essentials Provider Data Management feature to quickly verify their directory information with us and other insurers every 90 days. Facilities must use the Demographic Change Form to verify their data.
• Learn more on our Verify and Update Your Information page.

Frequently Asked Questions

CAQH ProView FAQs

CAQH Provider Quick Reference Guide

CAQH ProView Provider User 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 ProView.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations, or warranties regarding third party vendors and the products and services they offer.

Activating your ProView Registration

Blue Choice PPO, HMO, PPO, Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM 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. It is now possible for providers to have a CAQH number created on their own. Go to the CAQH website , select the "Register Now" option and complete the online form. 
2. CAQH will email you a Welcome kit with registration instructions, along with your personal CAQH Provider ID, allowing you to obtain immediate access to the ProView 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 ProView 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 the CAQH website and enter your username and password
   • Click the Authorize tab (located on the bottom left of main page)
   • 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 ProView 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 ProView 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 ProView  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 
  Upload supporting documents directly on the ProView website. 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 ProView 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 ProView database.

Visit the CAQH website  for more information about the ProView database and the application process.  

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 Pre-application Form

Your application will not be considered complete without these documents.

To check the status of your credentialing process, enter your NPI or license number in our Credentialing Status Checker.

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 ProView 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 ProView database for us to access during the credentialing and recredentialing process. Only the health plans that participate in the ProView 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.

Reminder: Verify Separately for the Provider Directory

Entering and attesting to data in CAQH ProView for the credentialing process doesn’t verify the information that’s needed for the federal Consolidated Appropriations Act (CAA). You must verify your provider directory information separately to meet CAA requirements.

• The CAA requires that certain directory information be verified every 90 days, even if your data hasn’t changed since you last verified it.
• We recommend that professional providers use the Availity^® Essentials Provider Data Management feature to quickly verify their directory information with us and other insurers every 90 days. Facilities must use the Demographic Change Form to verify their data.
• Learn more on our Verify and Update Your Information page.

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 ProView 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 ProView 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 ProView credentialing process. If so, we will be able to obtain current information from the ProView database and complete the recredentialing process without having to contact you.

CAQH Tool Verifies Credentialing Information

We’re working with VERISYS to verify your credentialing data after you enter it into ProView. VERISYS may contact you on behalf of BCBSIL and request that you:

• Re-attest to your data’s accuracy, or
• Complete your credentialing application by entering or attaching missing information in CAQH ProView

Once the recredentialing process is completed you are considered approved unless otherwise notified. If not approved, a letter with details will be mailed within 10 business days.

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 2016 through 2019 is below.

N: Notification is sent to provider with the SSN ending in that specified number based on year/month (one month notification period is allocated)

C: Collection of data process starts to receive information from re-credentialed party (60 day collection period is allocated)

OPEN: The Health Plan cannot collect re-credentialing data, except as noted in subsection (a) (6 month period)

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, Blue HPN^SM and the HMO products. 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 HMO products.
• The Blue Advantage HMO 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 HMO products
• The Blue Precision HMO 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 HMO products.
• The Blue Focus Care HMO 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 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 Blue HPN 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.