Practitioner Credentialing Application

Instructions

Read all instructions carefully prior to submitting your application. Claims should not be submitted until you receive notification of an approved application.

Requirements for completion

Complete only this application. Do not use another insurance plan’s application.

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 this form.

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.

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. 

Personal Information

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

*Required fields

General Information

Professional IDs

Include all state license, DEA registrations and SAMHSA waivers. If not applicable, put N/A

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

*Required Fields

Other ID Numbers

Note: Medicaid Expansion providers must be enrolled with Medicaid. 

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 

Training

List postgraduate training programs you attended. Use one section per institution. 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.

Work History

Include a chronological work history for the past five years. Current position appears in Practice and Specialty section. 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

Work History Details

Provide information on any gaps in your work history and include timeframes in month/year format.

Practice Location and Specialty Information

TIP: Your Individual Tax ID is assumed to be your primary Tax ID unless you specify otherwise to the right. Billing NPI refers to the NPI that would be placed in box 33a on a paper CMS 1500 claim form.

IMPORTANT: Include a copy of your W-9 for each Tax ID referenced in this application.

*Required fields

Additional Practice Information

List additional locations that use SAME TAX ID as listed above that you wish to have listed in BCBSND's provider directory (only listed if you select 'Yes' to 'Display in Directory'). Billing NPI refers to the NPI that would be placed in box 33a on paper CMS 1500 claim form (or corresponding electronic field). If more space is needed, include additional documentation as an attachment.

Additional Directory Location

If Tax ID is different from location listed in previous Section 

TIP: List additional practice location for directory. Billing NPI refers to the NPI that would be placed in box 33a on paper CMS 1500 claim form (or corresponding electronic field). If more space is needed, include additional documentation as an attachment.

IMPORTANT: Include a copy of your W-9 for each Tax ID referenced in this application. 

*Required fields

Admitting Privileges

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

*Required fields

Disclosure Questions

Answer all questions. If a question does not apply, answer 'No'. Provide a detailed explanation for any 'Yes' answers to the questions below. Attach additional documentation if necessary. 

*Required fields

Disclosure Question Details

Attach supporting documentation if necessary.

Max size for upload is 10MB. Acceptable file formats include: .pdf, .doc, and image files.

    Behavioral Health Providers Capability/Services

    Please check all capabilities in which you are certified or have received specific or on-going training. These may or my not be covered benefits.

    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 10MB. Acceptable file formats include: .pdf, .doc, and image files.

      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 10MB. Acceptable file formats include: .pdf, .doc, and image files.

        Consent

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

        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 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 true and accurate to the best of my knowledge and belief.

        Credentialing Contact Information

        Mailing Address for Credentialing Correspondence

        Almost done! Review your information.

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

        Print this page for your records before submitting the application.