Credentialing overview
Quick reference guide
Why does Capital Blue Cross credential providers?
Our provider credentialing program is an objective and systematic process to review the credentials of all providers who apply to participate in our networks and support our managed care products. We utilize procedures that comply with the National Committee for Quality Assurance (NCQA), the Centers for Medicare and Medicaid Services (CMS), and the Commonwealth of Pennsylvania Department of Health (DOH) regulations.
What provider types are required to be credentialed?
Our uniform credentialing program is applicable to all providers participating in Capital Blue Cross, Capital Advantage Insurance Company (CAIC), Capital Advantage Assurance Company, (CAAC), and/or Commercial HMO, and Medicare Advantage networks.
How do I begin the credentialing process?
New groups that are not currently contracted with Capital Blue Cross can begin the contracting and credentialing process by visiting our join our network page. Existing groups can submit requests using the Capital Blue Cross Provider Maintenance Tool. The tool can be accessed via the Applications tab of our online provider portal.
For providers with an existing contract with Capital Blue Cross, ProView, the standardized national online credentialing system developed by CAQH, is used as our exclusive provider credentialing system. All providers must use the CAQH ProView system for credentialing and recredentialing. Healthcare providers must self-register with ProView before we will initiate the application process.
How long does the process take to complete?
Credentialing information, including but not limited to, application, attestation, and all primary source verification for all providers cannot be older than 180 days at the time of the credentialing committee decision.
If approval cannot be obtained within the 180-day timeframe, the provider will be required to update their application and attestation form on the CAQH ProView website. Any primary source verifications that exceed the 180-day timeframe will be re-verified.
Capital Blue Cross will notify participating physician providers of decisions on credentialing matters within 60 days from a decision by the credentialing committee.
Notification of the completion of the credentialing process does not finalize participation within the Capital Blue Cross network(s). A second notice of participation in our networks will be issued confirming the provider’s effective dates. Providers should not schedule services with Capital Blue Cross members until this notification is received.
Capital Blue Cross completes the recredentialing process at least once every three (3) years. Capital Blue Cross policies require providers to be recredentialed for the protection of our members, and is consistent with NCQA, CMS, and Pennsylvania’s Department of Health regulations. The recredentialing process includes most of the same components as initial credentialing with an additional quality component added for review.
Professional provider types
The following Professional provider types are required to be credentialed and recredentialed:
Professional provider types |
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Audiologist |
Optometrist |
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Acupuncturist |
Oral Surgeon |
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Behavioral Health Practitioners1 |
Occupational Therapist |
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Certified Nurse Midwife |
Physical Therapist |
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Certified Nurse Anesthetist (practicing outside the inpatient or free standing facility setting) |
Physician (MD, DO and Telehealth) |
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Certified Registered Nurse Practitioner |
Physician Assistant (Certified) |
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Chiropractor |
Podiatrist |
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Dietitian - Nutritionist |
Prosthodontist |
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Neuropsychologist |
Speech Language Pathologist |
1Behavioral Health Practitioners include: Psychiatrists, Clinical Social Workers, Social Workers, Clinical Nurse Specialists, Master's Prepared Therapists and Licensed Behavioral Specialists.
Need additional information?
Detailed information related to our credentialing process can be found in the Capital Blue Cross Provider Manual.