BlueCross BlueShield North Carolina Credentialing Services

To produce a policy (“Policy”) defining the Prepaid Health Plan’s Centralized Provider Enrollment and credentialing procedure, as needed by the State of North Carolina Department of Health & Human Services, Division of Health Benefits, Modified and Reaffirmed for Proposal Prepaid Health Plan Services (“State Contract”) to decide whether to approve a Request.

Centralized Credentialing and Re-credentialing Process (“CCRP”): Procedures approved by the Government with an assigned vendor to collect information and verify credentials for all Providers currently enrolled or seeking to enroll in the State Medicaid programme via a centralized credentialing process. To enroll in the Medicaid programme, the information will be gathered, verified, and maintained. The procedure and information needs will be in accordance with the most recent data and processing standards for a credentialing process for an accredited health plan with accreditation from the chosen, nationally recognized accrediting organization, as well as the standards found in 42 C.F.R. Part 455 Subparts B and E. The Department has chosen the National Committee for Quality Assurance to accredit the Program. Providers will use a single, computerized application to provide information that will be validated and reviewed in order to become a Medicaid enrolled Provider, with the application functioning as both a Medicaid service charge and a Medicaid controlled care Provider enrolment.

Our Specialist will assist you in getting credentialed as soon as possible!

We will review your educational history, career experience, credentials, and registration to practice in the healthcare industry during the credentialing process. Throughout the credentialing process, we will monitor your progress to determine your education, training, credentials, and registration to practice in a health care setting. We will examine all of your documents to ensure that you have been certified by one of the world’s most prominent healthcare providers. As a team, we are devoted to long-term growth. We will help you obtain the services you desire. This is how we show our appreciation to our customers and demonstrate our commitment to providing great customer service.

Initial Credential

To begin, each Provider must participate in the Department’s Medicaid and NC Health Choice programmes. The Department will ensure that all programme requirements and prerequisites are met by the candidates.

Based on state and federal requirements:

• Federal and state application fee

• Training

• Fingerprinting

• Site visits

• Criminal background checks

• Federal database checks

• Verification of provider certification, license and accreditation

The Department will enter into a contract with a PDC to complement existing provider registration and credentialing data needed to make the PHP’s capacity to make Quality Judgements during provider Medicaid Managed Care network contracting activities. The Department will screen, register, and confirm back all PHP network providers as Medicaid providers using the universal credentialing method.

When accessible, the Department or its designee will primary source verify the following data about care Practitioners without contacting the Provider:

• Current license

• Current DEA/CDS certification

• Current board certification status

• Highest level of education and training

Last five (5) years of:

• State licensing board sanctions

• Medicare/Medicaid sanctions

• Malpractice history

• Work history including gaps

Anti - discrimination Announcement

BCBS NC will not discriminate against any applicant for participation in its programmes or provider network(s) based on race, gender, color, creed, religion, national origin, ancestry, sexual orientation, age, veteran, or marital status, or any other unlawful ground not expressly stated above.

Furthermore, BCBS NC will not discriminate against any candidate based on the risk of the community they serve or those who specialize in the treatment of expensive disorders. This includes, in addition to gender and language capabilities, which are supplied to members to match their needs and desires.

This information is not required in the contracting process. Decisions are based on issues of professional conduct and competence as reported and verified through the contracting process. BCBS NC policies and processes will not discriminate against any Provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification with regards to participation, reimbursement or indemnification.

Considerations for Selecting and Retaining Practitioner Credentialing

This information may be obtained through the PDC File, as a result of an adverse occurrence, or through continual monitoring. The Provider will not be contacted for this information.

New Applicants (Credentialing) Must have a current, valid, unencumbered, unrestricted, and non-probationary license in the state(s) where he/she provides services to Healthy Blue members, unless the applicant’s licensure action was related to substance abuse, physical impairment, or mental illness, and the applicant demonstrated a minimum of two (2) years of successful participation in a treatable condition.

Must not currently be sanctioned, prohibited, or excluded from participating in any of the following government programmes: Medicare, Medicaid, or the Federal Employee Health Benefit Program are all options.

Malpractice judgments and settlements will be examined:

The Provider Network Participation Committee will personally assess and consider providers who have one (1) or more of the following malpractice case histories.


• Must not be currently sanctioned, prohibited, or excluded from participation in any of the following federal programmes: Medicare, Medicaid, or FEHBP. If, after participating in BCBS NC’s programmes or provider network(s), a Provider is sanctioned, debarred, or excluded from the Medicare, Medicaid, or FEHBP programmes, the Provider will become immediately ineligible for participation in the applicable government programmes or provider network(s), as well as BCBS NC’s other credentialed provider network(s) at the time of identification (s).

• A current, valid license to practice in each state where the practitioner offers care to PHP members is required.

• Following the approval cycle, the Provider’s malpractice case history will be examined. If no new cases have been detected since the last review, the malpractice history will be evaluated to see if it meets the requirements. If there is a new malpractice history, a minimum of the latest five (5) years of malpractice history is assessed, and criteria consistent with original credentialing are utilized.

Re-credentialing Timelines

Unless otherwise required by the State Contract or State rules, all applicable Providers in the BCBS NC network within the scope of the BCBS NC credentialing programme must be re-credentialed every three (3) years.

BCBS NC will re-credential Providers in the following ways:

• No less than every five (5) years during the professional credentialing transitional phase.
• No less than every three (3) years after the physician credentialing transitional phase.

BlueCross BlueShield North Carolina Phone Number

Call at here: 1-888-206-4697 if you want to entertain your anyqueries.

BlueCross BlueShield North Carolina Email Address

Email: Send a message to We are here to furnish your every question in your mind.

BlueCross BlueShield North Carolina Enrollment Form

Study and follow the guidelines from that site link:

House of Outsourcing Billing Services

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