Credentialing Process for Physicians and Professional Providers
Credentialing is the process by which Blue Cross and Blue Shield of Montana (BCBSMT) reviews and validates the professional qualifications of physicians and certain other providers who apply for participation with our health care organization, ensuring that they meet the professional standards.
All physicians and professional providers must successfully complete the credentialing process prior to participation in the BCBSMT provider networks as outlined in the Provider Network Participation Policy .
Effective September 2014, the Council for Affordable Quality Healthcare, Inc. (CAQH) will collect the data required for our credentialing and recredentialing process. CAQH uses an electronic database, entitled ProView, to collect the data. This online credentialing application process supports our administrative simplification and paper reduction efforts. This solution also supports quality initiatives and helps to ensure the accuracy and integrity of our provider database.
After the BCBSMT Provider Record ID is set up:
- BCBSMT will roster your name with the Council for Affordable Quality Healthcare, Inc. (CAQH)
- At any time, you may register online and obtain immediate access to the CAQH ProView online application tool and complete your credentialing application.
- Provider must authorize BCBSMT to view their credentials. (Only organization(s) the provider authorizes will have access to their data.)
- CAQH will automatically transmit credentialing information to BCBSMT
- BCBSMT may need to clarify application details and will contact the provider if necessary.
Note: Providers may utilize CAQH ProView at no cost.
After a completed application is received, BCBSMT verifies the applicant's data. Then, the Credentialing Committee evaluates the applicant's professional qualifications, such as training, licensure, certifications, and background as well as professional competence and conduct, as summarized in the standards.
When the process is complete, the applicant receives written notification of his/her credentialing status with BCBSMT.
The applicant then receives a second written notification indicating his/her professional status with BCBSMT, the effective date of the contract/agreement and a copy of the executed agreement.
Note: The effective date of the agreement is the credentialing approval date. Effective dates are not backdated.
For more information on the CAQH application process, go to Getting Started with CAQH .
Provider Rights: Applicants applying or reapplying for participation or continued participation in the Health Plan networks have the right to be informed of the following:
- Right to review information submitted on or with their credentialing and recredentialing application;
- Right to correct erroneous information;
- Right to be informed of the status of their credentialing or recredentialing application, upon request.
Applicants should direct all requests to their Network Management Representative. The Enterprise Credentialing Department will notify the Applicant in writing if erroneous information is discovered during the verification process from any primary source. Applicants will be given sufficient time to correct erroneous information and resubmit to the Enterprise Credentialing Department. It will be the Applicant's responsibility to work directly with the reporting entity(ies) to correct the erroneous information.