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.

Groups that are not currently participating with Capital Blue Cross can begin the contracting and credentialing process by following the guidelines below.

Who must 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.

The following professional Provider types are required to be credentialed and recredentialed:

Professional provider types

Audiologist

Optometrist

Acupuncturist

Oral Surgeon

Behavioral Health Practitioners1

Occupational Therapist

Certified Nurse Midwife

Physical Therapist

Certified Nurse Anesthetist (practicing outside the inpatient or free standing facility setting)

Physician (MD, DO and Telehealth)

Certified Registered Nurse Practitioner

Physician Assistant (Certified)

Chiropractor

Podiatrist

Dietitian - Nutritionist

Prosthodontist

Neuropsychologist

Speech Language Pathologist

1Behavioral Health Practitioners include: Psychiatrists, Psychologists, Clinical Social Workers, Social Workers, Clinical Nurse Specialists, Master's Prepared Therapists, and Licensed Behavioral Specialists.

Per PA Act 4 of 2024, Capital allows LAPCs and LAMFTs to bill under the supervising practitioner. Credentialing for these associate licensees is not required until full licensure.

Credentialing process

Capital Blue Cross uses CAQH ProView, a standardized national online credentialing system developed by the Council for Affordable Quality Healthcare. It serves as our exclusive provider credentialing system. All providers must use the CAQH ProView system for credentialing and recredentialing.

New users:

  1. Submit a Capital Blue Cross network participation request via join our network.
  2. Register using CAQH ProView to complete your application and obtain a CAQH ID.
  3. Within the ProView portal, please authorize Capital Blue Cross to access your CAQH profile or grant Global Authorization.

Existing users:

  1. Ensure the new practitioner has completed the CAQH process (steps 2 and 3 above).
  2. Log in to Capital’s provider portal (Availity Essentials).
  3. Add the new practitioner. Helpful instructions can be found in Capital’s Adding a Practitioner Tip Sheet.

What to expect

  • Capital Blue Cross will notify providers of credentialing decisions within 60 days following credentialing committee review.
  • Notification of the completion of the credentialing process does not finalize participation within the Capital Blue Cross network(s).
  • Providers should not schedule services with Capital Blue Cross members until a second notification of participation in our networks has been issued. This notification will confirm the provider’s effective dates.
  • Credentialing information, including the CAQH application, attestation, and primary source verifications, must be current and dated within 120 days of the credentialing committee decision.
  • If the credentialing process extends beyond 120 days, providers may be required to update their CAQH information and complete any necessary re-verifications.

Recredentialing

In accordance with NCQA, CMS, and Pennsylvania’s Department of Health regulations, Capital Blue Cross policies require providers to be recredentialed at least once every three (3) years.

  • Review and update your CAQH profile before re-attesting. All credentialing information, attestations, and required verifications must be current and within 120 days of the credentialing committee decision.
  • Verify that Capital has the correct email addresses and phone numbers for your credentialing contacts in our provider portal (Availity Essentials). If updates are needed, refer to Capital’s Updating Addresses or Demographics tip sheet.

Important reminder

Failure to maintain an active CAQH profile, or re-attest to CAQH may result in termination from Capital’s network and will be considered intent to terminate participation. If participation is terminated due to an expired or outdated CAQH application or incomplete recredentialing requirements, the provider must update and re-attest their CAQH application and submit a new participation request for reconsideration in the network.

Need additional information?

Detailed information related to our credentialing process can be found in the Capital Blue Cross Provider Manual.