Apply for Credentialing
BCBSNC Special Instructions for Doctor of Optometry /Doctor of Psychology or Doctor of Philosophy/Physical Therapist/Occupational Therapist/Licensed Speech Pathologist Audiologist/Chiropractor or Respiratory Therapists
Dear Health Care Provider:
This application is the "Uniform Application to Participate as a Health Care Practitioner", 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). 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 three of the Uniform Application:
- Copy of CV to include all work history after graduation from appropriate 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 (If applicable).
- 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.
- 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 two letters of recommendation from physician peers are required.