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Credentialing Q & As

Here are some answers to questions we frequently get asked about the credentialing process. They are organized by topic.

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Admitting privileges
Do I need admitting privileges?

Please review our credentialing and recredentialing requirements for your specialty to get information on admitting privilege requirements.
Professional Credentialing and Recredentialing Guidelines
Dental Credentialing and Recredentialing Guidelines

Board certification
Do I need to be board certified?

Some provider types require board certification or have specific training requirements. See credentialing guidelines for details:
Professional Credentialing and Recredentialing Guidelines
Dental Credentialing and Recredentialing Guidelines

Certified registered nurse anesthetist (CRNA) requirements
When should a certified registered nurse anesthetist (CRNA) complete a full application?

If the CRNA is employed by a CRNA practice:

  • They should complete the CRNA contracting application.

If the CRNA is: 1) employed by an ambulatory surgery center, OR 2) affiliated with a physician anesthesiology practice that bills for their services:

  • They should NOT complete the CRNA contracting application.

CRNAs employed by an anesthesiology/MD group practice do not need to be credentialed/contracted by Blue Cross Blue Shield of Massachusetts. CRNAs in this scenario should obtain a non-participating courtesy number for Medicare cross-over claims processing.

Coverage arrangement
Do I need to have a covering arrangement to participate with Blue Cross?

Arranging for coverage after hours and during illness or vacation is a Blue Cross contractual requirement. Covering providers must participate in the same Blue Cross products as you do. See specific requirements for your provider type in the Professional Credentialing and Recredentialing Guidelines

Note: You cannot be your own covering provider. On the application, please do not enter your own name as covering provider.

DEA number requirements
When is a DEA certificate required?

If you have prescriptive authority, we’ll need a copy of your Federal Drug Enforcement Administration (DEA) Certificate. (Exception: Optometrists must submit a copy of their Massachusetts Controlled Substances Registration (MCSR).)

Please review our credentialing and recredentialing requirements for your specialty for details about whether a DEA number is required:
Professional Credentialing and Recredentialing Guidelines
Dental Credentialing and Recredentialing Guidelines

Diagnostic imaging services
How do I apply to perform diagnostic imaging services?

If you perform the technical or professional component of diagnostic imaging, you must apply to be privileged. Please complete the privileging application that applies to the services you would like to perform.

If you plan to bill for: Then use the:
Professional component of diagnostic imaging Professional Privileging Application
Technical component of x-rays, ophthalmic A scans, and limited or follow-up obstetrical ultrasounds Limited Technical Privileging Application
Technical component of modalities such as specialized ultrasounds, MRIs, or angiography TDI Privileging Application

For more information, go to the Privileging page.

When can a practitioner start seeing Blue Cross members?

We will email a new practitioner a welcome letter showing the Blue Cross Product (network) participation and contract effective date; this is when they may begin treating our members.

Whenever you submit an application or request form, be sure to clearly enter the email address where you would like to receive the response.

Why am I getting calls from Verisys or Blue Cross when I have completed CAQH?

We may be missing information we need to complete your credentialing process. Even though CAQH may not require this information, it is best to store the information in CAQH and ensure it is up-to-date at re-attestment. Some common data elements that Blue Cross and VerisysTM have to outreach for are:

  • Malpractice insurance information
  • References and past insurance coverage if there is no hospital affiliation
  • The name of a participating provider who will be prescribing for the practitioner when there is no DEA
  • Current Advanced Nurse Certificates
  • Collaborating/supervising physicians
  • Admitting arrangements for physician assistants and ancillary advanced practice nurses

I would like to enroll a new provider. Do they need to complete the credentialing process?

  • If you are enrolling a provider who is already contracted with us, your provider does not need to be credentialed again. This request is considered a ‘link’ or a ‘business entity change.’
  • If the provider is new and not already contracted with Blue Cross, this provider must first complete the credentialing process before we can execute a contract and enroll the provider. Remember:
    • Be sure to register and complete an online CAQH application.
    • You may start the credentialing process before the contract is received. The contract is not required to start the credentialing process.
    • Ancillary and behavioral health clinicians must submit a contracting application. (We will send an Attachment A for the clinician's signature.)

Hospital-based physicians
I am a hospital-based physician and do not care for members outside the hospital. Do I need to be credentialed?

You can contract with us without going through the credentialing process, but can only bill for services provided within the hospital.

If I leave my hospital-based position, do I have to be fully credentialed with Blue Cross Blue Shield of Massachusetts?

Yes. A physician enrolled as a non-credentialed, hospital-based provider who wants to practice outside of a hospital-based setting must be fully credentialed.

How often do I recredential?

Professional and dental providers must recredential every two years during the month of their birthday. Institutional providers must recredential every two years from their anniversary date.

For professional and dental providers only:
To ensure a smooth recredentialing cycle, be sure to review your application in CAQH.

  • Update all expired information (malpractice insurance, collaborating/supervising physicians, admitting arrangements, etc.)
  • Re-attest to your application’s accuracy
  • Professional and dental providers are contractually required to review, update, and attest to their information in CAQH every 90 days.

I was recently credentialed with Blue Cross and I just received a recredentialing package. Do I need to complete this? 

Yes. We recredential professional providers on a two-year cycle based on their birthday. To get you started on the two-year cycle, you may need to recredential soon after your initial credentialing.