Provider Credentialing Process
Change in Participating Effective Date Policy
Effective April 1, 2008, all physicians and other health care professionals must be credentialed before they can participate in a Regence provider network. Learn more.
Regence BlueCross BlueShield of Utah (Regence BCBSU)
recognizes that strong provider networks are essential
for the delivery of quality health-care services and
appropriate resource management of health-care resources.
Credentialing is now required for all Regence BlueCross
BlueShield of Utah lines of business. Basic review of
application information and licensure is required for
all Regence BCBSU providers. All provider types are
credentialed to participate in the TRICARE/CHAMPUS program.
The credentialing decision will apply to all lines of
business with which the provider participates.Credentialing criteria is consistent with national
accreditation standards as established by NCQA, HCFA
(now the Centers for Medicare and Medicaid Services
or CMS) and state and federal agencies such as Medicaid
and TRICARE/CHAMPUS.The credentialing program includes the following components:
- Application
- Primary source verification
- Office review
- File review
- Credentialing/Provider Practice Committee decision
Facilities will be recredentialed every three years
to ensure they continue to be in good standing with
state and federal regulatory agencies and in compliance
with Regence BCBSU’s facilities’ process
and procedures. Contracted professional providers within
the credentialed networks are recredentialed every two
years.The credentialing process provides the mechanism for
determining and validating the qualifications of applicants
for inclusion on Regence BCBSU provider panels. The
process includes review of the following:
- Current valid/unrestricted license
- Hospital/facility privileges in good standing
- Valid/unrestricted DEA certificate
- Board certification/eligibility
- Education/training
- Work history
- Current malpractice liability insurance
- Professional liability claims
- National Practitioner Data Bank history
- Medicare/Medicaid status
- Division of Occupational and Professional Licensing
status
- Credentialing/Provider Practice Committee information
Other factors that are considered in the credentialing
process include:
- Geographic access
- Fraud and abuse
- Utilization management
- Consumer or practitioner complaints
- Other relevant information
The Credentialing/Provider Practice Committee makes
the final determination of approval or denial for all
providers.
Change in Participating Effective Date Policy
Effective April 1, 2008, all physicians and other health care professionals must be credentialed before they can participate in a Regence provider network. Beginning April 1, 2008, the following policy will apply to all participating providers:
- New provider agreements will have an effective date of the first day of the month in which the provider was credentialed (e.g., if credentialing was approved on June 14, the agreement will be effective on June 1).
- If Regence does not receive a signed agreement in the same month as credentialing is completed, the agreement effective date will be the first of the month in which credentialing is approved or the signed agreement is received, whichever is later.
- A new provider joining a group or clinic agreement will have an effective date of the first day of the month in which he or she was credentialed (e.g., if credentialing was approved on June 14, the effective date of participation will be June 1).
- If a provider already participating with Regence adds an additional network, the effective date of the new network will be the first day of the month the signed agreement is received.
- Regence will no longer establish retroactive agreement effective dates.
- Claims submitted to Regence for dates of service prior to the provider’s effective date will be processed as out-of-network.
If you have any questions regarding this policy, please contact your provider consultant.
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