Credentialing Process for Office Based Physicians or Professional Providers

All office-based physicians or professional providers who participate in our networks are required to complete a credentialing process prior to acceptance.

Step 1: Review Credentialing Requirements

Before you submit your Texas Credentialing application:

• Review the TX Initial Credentialing Checklist to ensure you have all information needed.
• Residency must be completed prior to being a contracted provider
• Physician Assistants must be board certified by the National Commission on Certification of Physician Assistants and maintain certification for continued participation

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 Network Management 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 granted 30 calendar days to correct erroneous and/or conflicting information and resubmit to the Enterprise Credentialing Department, your assigned Network Management Consultant or the Medical Director. It will be the applicant's responsibility to work directly with the reporting entity to correct the erroneous and/or conflicting information.

Types of Professional Providers Requiring Credentialing

BCBSTX requires full credentialing of office-based physicians and other professional providers listed on the Types of Professional Providers Requiring Credentialing List for participation in their managed care networks.

An applicant in a training program is not eligible to be considered for network participation.

Expedited Credentialing Process

BCBSTX will provide an expedited credentialing process which allows for a "provisional network participation" status if the provider applicant has:

• A valid BCBSTX Provider Record ID for claim payment
• Submitted a current signed BCBSTX contract/agreement
• Upon receipt of a complete CAQH ProView application with “global” or “plan specific” authorization to BCBSTX or a complete TDI application’ **
• A valid license in the state by, and in good standing with, the Texas Licensing Boards.

** Providers will be notified once the CAQH credentialing applications are reviewed for completeness. The review takes on average 8–10 calendar days.

• If the applicant does not meet the "provisional network participation" requirements, the applicant must be fully credentialed and approved prior to being made effective.
• The licensing board for Psychologists (PhDs) does not provide a quick verification method of a provider's license. PhDs will be fully credentialed and made effective after credentialing approval.
• Credentialing is a very involved and timely process. Please allow for a sufficient period of time for the full credentialing process to be completed, before checking on status with BCBSTX. Status can be checked by referring to the Case and Credentialing Status Checkers.

Initial Credentialing and Recredentialing Process

Note: BCBSTX utilizes the services of Verisys ® (formerly Aperture) as our Centralized Verification Organization. All new and currently contracted providers with BCBSTX will begin to receive notifications from Verisys regarding:

• Initial credentialing events; and
• Information about the newly assigned Verisys common recredentialing date**.

Step 2: Complete a Credentialing Application

BCBSTX requires physicians and other professional providers to use the Council for Affordable Quality Healthcare's ® Provider Data Portal for initial credentialing and recredentialing. CAQH, a free online service, allows physicians and other professional providers to fill out one application to meet the credentialing data needs of multiple organizations. The CAQH Provider Data Portal database 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. Refer to CAQH Credentialing FAQ’s below for more information.

Note: The requirements of creating and/or updating your CAQH profile is important. Failure to finalize your CAQH application within 45 days will cause the BCBSTX credentialing process to be discontinued and you will be required to start the process over.

CAQH Approved Provider Types

Texas physicians and other professional providers who have a provider type listed in the CAQH Approved Provider Types List must apply for initial or continuing participation with BCBSTX through the CAQH Provider Data Portal database by accessing the CAQH website.

For details on how to get started with CAQH, view the Getting Started with CAQH guide.

Exceptions to CAQH:

1. BCBSTX's requirement of use of the CAQHProvider Data Portaldatabase does not apply to physicians and other professional providers participating through delegated credentialing agreements/contracts or are solely practicing in a hospital-based environment.
2. Texas physicians and other professional providers who do not have a provider type listed in the above CAQH Approved Provider Types list must go to the TDI website to access and complete a Texas Standardized Credentialing Application, and fax or mail to BCBSTX the completed application along with the required supporting documents referenced below:
   • State medical license(s)
   • Drug Enforcement Administration (DEA) Certificate
   • Malpractice insurance face sheet
   • Summary of any pending or settled malpractice case(s) - if within 10 or less years old
   • Curriculum Vitae
   • Signed Attestation (page 18 of online application — print and sign)
   • Written Protocol (Nurse Practitioners only)
3. Forward completed credentialing application packet to BCBSTX:
   Fax to:972-996-8230(preferred method)
   or
   Mail to:
   Blue Cross and Blue Shield of Texas
   Attn: Enterprise Credentialing
   PO Box 65067
   Dallas, TX 75265-0267

Facility Privileges Requirements for Office-Based Providers

Certain office-based professional specialties who routinely perform procedures in a facility setting, must have privileges at an in-network facility where those procedures are performed.

Professional providers should refer to the TX Office-Based Provider Facility Admitting Privileges Requirements List to identify if your specialty requires admitting privileges and for the acceptable Facility types.

You may be permitted to submit a signed Facility Coverage Letter in lieu of privileges, if indicated on the TX Office-Based Provider - Facility Admitting Privileges Requirements List. Note: Facility Coverage Letter must be submitted along with the onboarding application.

CAQH Credentialing Frequently Asked Questions Learn more

Verisys (formerly trademark of Aperture Credentialing, LLC) is, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. "Verisys" provides administrative services to BCBSTX. If you have any questions about the products or services offered by such vendor, you should contact the vendor directly.