Apply for Credentialing
BCBSNC Special Instructions for Board Certified Medical Doctor/Doctor of Osteopathy/Doctor of Dental Science or Doctor of Dental Surgery/Doctor of Medical Dentistry/Doctor of Podiatry
Dear Health Care Provider:
This "Uniform Application to Participate as a Health Care Practitioner" was developed by the North Carolina Department of Insurance pursuant to North Carolina General Statute 58-3-230.
The following instructions will help you to avoid delays associated with an incomplete application. Please review this material carefully before attempting to complete the Uniform Application. Fill in all required information completely and attach all required documents before submitting your application.
Blue Cross and Blue Shield of North Carolina (BCBSNC) will notify you of an incomplete application within 15 days of its receipt requesting the information to complete your application. Your incomplete application will be closed 60 days from receipt if the requested information is not received. Upon completion of the credentialing process, you will be presented to the Credentialing Committee for approval or denial. If denied you will be notified by certified mail. If approved you will be notified by BCBSNC's Network Management informing you of your effective date to see BCBSNC managed care members.
ALL APPLICANTS: Please note all fields must be COMPLETED or indicate NOT APPLICABLE (NA)
- Provide education/practice history from beginning of your education in your field of expertise up to your current practice location (must include months/years and account for any gaps greater than three months). Note this information may be submitted on your Curriculum Vitae (CV) and reference sections B 1-5 of the application as "see attached CV".
- Provide the following documents on page two of the Uniform Application for Dentists please use Dental Uniform Application:
- Copy of CV to include all work history after graduation from Medical or Osteopathic School (CV must account for any gaps of 90 days or more)
- Federal and/or State DEA Registration
For DEA certificates that do not include the full schedule for prescribing, we request that you include an explanation regarding the limited schedules in order to facilitate consideration of your credentials.
- Certificate of Insurance of at least $1 million per occurrence and $3 million aggregate
Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider (s) covered, coverage amounts, effective date, expiration date, and policy number.
- Copy of CLIA (Clinical Laboratory Improvement Amendments) / ACR (American College of Radiology)
- The original, unaltered Attestation Statement containing the provider's original signature and date must be submitted with your application.
- If you have a single medical malpractice judgment case settled for $200,000.00 or more; or if you have multiple malpractice cases settled for any amount a letter of recommendation from the Chief of Staff or the Chief of Department where you currently have hospital privileges is required. If you do not have admitting privileges, two letters of recommendation from physician peers may be submitted.
Attention: Providers applying for the specialty of Pain Management
Please click for specific training criteria required for the credentialing of Pain Management providers.
Attention: Providers applying for the specialty of Sleep Medicine
Please click for specific training criteria required for the credentialing of Sleep Medicine providers.