Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to offering our members access to provider networks, supported by highly-qualified and competent providers, delivering the best patient care available.
To support this commitment, Blue Cross NC reviews and validates providers’ credentials to support the selection and retention of individual practitioners, based upon their qualifications to meet our members’ health care needs. We make these reviews through our credentialing process, requiring individual practitioners to meet a minimum set of credentialing criteria, based upon their specialties of care.
We require providers to be credentialed with us before they become eligible to perform in-network services for our members. We also require providers to be re-credentialed with us every three years.
In the past, we allowed nurse practitioners (NPs), physician assistants (Pas), and certified nurse midwives (CNMs) to provide services to our members, without completing the credentialing process. After careful evaluation, we have determined mid-level providers (NPs, PAs, and CNMs) should also be credentialed by us. This is consistent with other health care practitioners, for eligibility to provide services within our commercially-offered managed care networks.
- Therefore, all NPs, PAs, and CNMs working with an in-network provider group and providing services for commercially-insured Blue Cross NC members, are required to complete credentialing with Blue Cross NC, on or before January 1, 2017.
- Additionally, any new-to-network NP, PA, or CNM will be required to complete credentialing with Blue Cross NC, in advance of providing in-network services for our members, beginning on and for dates after January 1, 2017.
Blue Cross NC is requesting NPs, PAs, and CNMs (or their organizational credentialing departments) to initiate credentialing with us as soon as possible. Instructions to begin the process are available on bluecrossnc.com. Simply access the “Providers” home page, and open the link located within the blue box, labeled “Become a Blue Cross NC Provider.”
The credentialing process can take up to 60 days from the date a credentialing application is received by Blue Cross NC, to complete. We adhere to the guidelines for credentialing, established by the National Committee for Quality Assurance (NCQA) and the North Carolina Department of Insurance (NCDOI). Following a NP’s, PA’s, or CNM’s completion of credentialing, the credentialed provider’s name and group affiliation will become eligible for display in Blue Cross NC’s online provider directory, “Find a Doctor.”
Failure to complete credentialing by January 1, 2017, may result in a mid-level provider’s inability to provide in-network services for Blue Cross NC’s commercial membership. We intend to conduct claims audits, and therefore, services determined to have been provided by a non-credentialed NP, PA, or CNM, after January 1, 2017, may be denied or adjusted, if the services were performed while working as part of, or under the supervision of a provider within an in-network health care organization.
We will revise our online provider e-manual, the Blue BookSM, to include the requirement for nurse practitioners, physician assistants, and certified nurse midwives to complete credentialing with Blue Cross NC, to become eligible to perform in-network services for Blue Cross NC’s commercially-insured, self-funded, and commercially-insured BlueCardSM Host membership.
As a reminder, it is important for you to regularly check the provider section of Blue Cross NC.com for updates to the Blue Book and Blue Cross NC’s online policies and procedures. Blue Cross NC’s posting of the Blue Book and other policies procedures, located on bluecrossnc.com, serves as our method of providing you with electronic notice about new and amended policies and procedures.
Please contact a representative of Blue Cross NC’s provider networks (formerly named Network Management) if you have questions about this new requirement for mid-level providers. We’re also happy to help you initiate the credentialing process, and are available by phone at 1-800-777-1643.