Practitioner Credentialing Application

Instructions

Completing this credentialing application and receiving notification of your approved application is required before claims can be submitted.

To protect your privacy, this form will timeout after 15 minutes of inactivity. There is no ability to save your progress, so we suggest gathering the information outlined in the left navigation to have on hand as you are completing the form and to allow a minimum of 15 minutes to complete it.

Complete all sections that are applicable to you. Include all additional information requested. Fields that include an asterisk (*) indicate that a response is required. All other fields will be considered not applicable if left blank.

To go back to a previous section, use the previous link on the bottom of the page or by clicking the section in the left navigation. Any data you have entered will remain on page. Do not use your browser back button to go to a previous form section, doing so will result in the loss of all form data entered.

If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.

Information you will need

Malpractice/liability insurance certificate

Facesheet which includes covered entity's name

All license/certification details ready such as license number, DEA number, etc.

Verification of Group Participation Agreement

Does your practice/organization have a Group Participation Agreement (contract) with BCBSND? Yes

In Progress

Unsure

Personal Information

BCBSND may use the information captured here for application follow-up.

*Required fields

First Name

Last Name

Suffix

Degree/Credential

Have you ever used another name? Yes

Gender Male

Female

Other/Non-binary

Date of Birth

Please enter a valid Date.

General Information

National Provider Identification (NPI) Number

Primary Specialty/Taxonomy

Primary Care Organization (PCP)? Yes

Languages Spoken

Street

City

9-Digit Zip

Phone

Fax

Professional IDs

IMPORTANT: DEA registration should match the state in which you work. Provide all current and previous license/certifications.

*Required Fields

Do you have a Federal DEA Number? Yes

Do you have a SAMHSA DEA Number? Yes

DEA Issue Date

Please enter a valid Date.

DEA Expiration Date

Please enter a valid Date.

License Number

License Issue Date

Please enter a valid Date.

License Expiration Date

Please enter a valid Date.

Are you currently practicing in this state? Yes

Remove

Add Another License +

Other ID Numbers

Note: Medicaid Expansion providers must be enrolled with Medicaid.

Medicaid ID Number

Medicare Number

CAQH ID Number

Education and Training

Provide the information for the school that issued your highest degree. Graduation date is also required. Fifth Pathway information is needed for non-U.S./Canadian graduates.

*Required fields

Highest Degree Achieved

Type U.S. or Canadian Graduate

Non-U.S./Canadian Graduate

Fifth Pathway Graduate

School Name

Degree Issued

Start Date

Please enter a valid Date.

Completion Date

Please enter a valid Date.

Street Address

City

State/Province

Zip/Postal Code

Phone

Fax

Training History

Include up to three postgraduate training programs you attended. Please explain any postgraduate training gaps of three months or greater in the Work History section. Residency institution and completion date required for MD or DO degree.

If none, check 'N/A'.

N/A

Institution/Hospital Name

Street Address

City

ZIP

Type Fellowship

Internship

Residency

Start Date

Please enter a valid Date.

Completion Date

Please enter a valid Date.

Remove

Add Another Institution +

Work History

Include a chronological work history for your last three previous employers over the past five years. If graduation date was less than five years ago, any work history from the date forward is sufficient. If there are any gaps in your work history, please explain in the space provided.

*Required fields

Have you worked in a professional capacity, prior to your current practice? Yes

Add Another Position

Admitting Privileges

List all current hospitals/institutions for which you have admitting privileges. If none, check 'N/A'.

*Required fields

N/A

Name of Hospital/Institution

Date Admitting Privileges Granted

Please enter a valid Date.

Street Address

City

ZIP

Remove

Add Another Hospital +

Supporting Documentation

Professional Liability/Malpractice Insurance Carrier

Attach a current copy of malpractice/liability insurance certificate which includes the following: practitioner name, policy name, policy number, coverage dates, coverage amounts. Credentialling application cannot be processed without this attachment.*

Max size for upload is 15MB. Acceptable file formats include: .pdf and image files.

Attach

Other

Attach other relevant documents to support the credentialing review. Consider attaching:

Certification
Licenses
Documents to attest to any of the disclosure questions requiring additional details

Max size for upload is 15MB. Acceptable file formats include: .pdf and image files.

Attach

Consent

Consent to the inspection of records and documents release of information and liability certification/attestation

Practitioner First Name

Practitioner Last Name

I Accept

I hereby authorize BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (BCBSND), its professional staff and legal representatives, to contact and consult with administrators and members of the professional staff of any treatment facility, institution, professional society, school, employer, law enforcement agency, or practice with which I have been associated, for the purpose of evaluating my professional competence, character, criminal history and ethical conduct. In addition, I consent to the inspection of all records and documents, including health records at other treatment facilities that may be material for evaluation of my professional qualifications by BCBSND, its professional staff and legal representatives. I release from liability all individuals or organizations for acts performed in good faith and without malice honestly initiated and in response to the inquiries authorized for use by BCBSND. I consent to the use of an electronic signature and understand that by typing my name in the signature space or (print name*) space in the Consent section of this application, I am affixing my electronic signature which has the same legal effect and enforceability as my handwritten signature. I agree that a photocopy of this authorization may be accepted with the same authority as the original.

I certify and attest to the fact that all of the information I have submitted in this application is complete, true and accurate to the best of my knowledge and belief.

Credentialing Contact Information

Application completed by (Name)

Credentialing contact name (if different than above)

Credentialing Correspondence

Street

City

ZIP

Phone Number

Business Fax

Almost done! Review your information.

Review each section below to view your entries and edit if necessary.

First Name : Edit

MI : Edit

Last Name : Edit

Suffix : Edit

Degree/Credential : Edit

Have you ever used another name? : Edit

Other First Name : Edit

Other Last Name : Edit

Date Started : Edit

End Date : Edit

Primary Care Organization (PCP)? : Edit

Gender : Edit

Date of Birth : Edit

SSN or ITIN : Edit

National Provider Identification (NPI) Number : Edit

Primary Specialty/Taxonomy : Edit

Languages Spoken : Edit

Street : Edit

City : Edit

State : Edit

9-Digit Zip : Edit

Email : Edit

Phone : Edit

Fax : Edit

Federal DEA Number : Edit

SAMHSA DEA Number : Edit

State of Registration : Edit

DEA Issue Date : Edit

DEA Expiration Date : Edit

License

License Number : Edit

License Issuing State : Edit

License Issue Date : Edit

License Expiration Date : Edit

Are you currently practicing in this state? : Edit

Medicare Number : Edit

Medicaid ID Number : Edit

State of Registration : Edit

CAQH ID Number : Edit

Type : Edit

School Name : Edit

Degree Issued : Edit

Start Date : Edit

Completion Date : Edit

Street Address : Edit

City : Edit

State/Province : Edit

Zip/Postal Code : Edit

Country Code : Edit

ECFMG Number : Edit

ECFMG Certificate Issue Date : Edit

Phone : Edit

Fax : Edit

Postgraduate Training : Edit

Postgraduate Training

Institution/Hospital Name : Edit

Street Address : Edit

City : Edit

State : Edit

ZIP : Edit

Type : Edit

Start Date : Edit

Completion Date : Edit

Previous Practice Employer

Previous Practice Employer Name : Edit

Street Address : Edit

City : Edit

State/Province/Country : Edit

Phone Number : Edit

Fax Number : Edit

Start Date : Edit

End Date : Edit

Work History Details : Edit

Tax ID Type : Edit

Group/Federal Tax ID : Edit

Individual Tax ID (SSN) : Edit

Billing NPI that will be submitted on claims : Edit

List languages spoken by office staff : Edit

Primary Care Organization (PCP)? : Edit

Are interpreters available? : Edit

Is this location handicap accessible? : Edit

Start Date : Edit

Age Range of Patients Accepted : Edit

Primary Practicing Specialty at this Location : Edit

Display in Directory? : Edit

Name of Certification Board : Edit

Initial Certification Date : Edit

Recertification Date : Edit

Expiration Date : Edit

Currently accepting new patients? : Edit

Physician/Group Practice Name to Appear in Directory : Edit

Group/Corporate Legal Name as it Appears on W-9 (if different from above) : Edit

Practice Street Address : Edit

City : Edit

State : Edit

9-Digit Zip : Edit

Appointment Phone : Edit

Business Fax : Edit

Website URL : Edit

Mailing Address : Edit

City : Edit

State : Edit

ZIP : Edit

Check Address : Edit

City : Edit

State : Edit

ZIP : Edit

Credentialing Contact Name : Edit

Email : Edit

Credentialing Mailing Address : Edit

City : Edit

State : Edit

ZIP : Edit

Phone Number : Edit

Additional Location

Start Date : Edit

Primary Practicing Specialty at this Location : Edit

Display in Directory : Edit

Billing NPI that will be submitted on claims : Edit

Currently accepting new patients? : Edit

Physician/Group Practice Name to Appear in Directory : Edit

Group/Corporate Legal Name as it Appears on W-9 (if different from above) : Edit

Does Business/Corporation have an existing agreement with BCBSND? : Edit

Practice Street Address : Edit

City : Edit

State : Edit

9-Digit Zip : Edit

Appointment Phone : Edit

Business Fax : Edit

Contact Email : Edit

Website URL : Edit

Mailing Address (If Different than Practice Address) : Edit

City : Edit

State : Edit

ZIP : Edit

Check Address (If Different than Practice Address) : Edit

City : Edit

State : Edit

ZIP : Edit

Tax ID type for additional directory location : Edit

Group/Federal Tax ID : Edit

Individual Tax ID (SSN) : Edit

Billing NPI that will be submitted on claims : Edit

List languages spoken by office staff. : Edit

Primary Care Organization (PCP)? : Edit

Are interpreters available? : Edit

Is the location listed below handicap accessible? : Edit

Start Date : Edit

Age Range of Patients Accepted : Edit

Primary Practicing Specialty at this Location : Edit

Display in Directory : Edit

Name of Certification Board : Edit

Initial Certification Date : Edit

Recertification Date : Edit

Expiration Date : Edit

Currently accepting new patients?* : Edit

Physician/Group Practice Name to Appear in Directory : Edit

Group/Corporate Legal Name as it Appears on W-9 (if different from above) : Edit

Practice Street Address : Edit

City : Edit

State : Edit

9-Digit Zip : Edit

Appointment Phone : Edit

Business Fax : Edit

Website URL : Edit

Mailing Address : Edit

City : Edit

State : Edit

ZIP : Edit

Check Address : Edit

City : Edit

State : Edit

ZIP : Edit

Admitting Privileges : Edit

Hospital/Institution

Name of Hospital/Institution : Edit

Date Admitting Privileges Granted : Edit

Street Address : Edit

City : Edit

State : Edit

ZIP : Edit

Do you currently have any physical impairment or disability that could, without reasonable accommodation, impede your ability to provide care according to accepted standards of professional performance or pose a threat to the health or safety of your patients? : Edit