Facility credentialing requirements

Product and network participation may vary by facility type and line of business. Credentialing requirements do not by themselves guarantee network participation or contracting eligibility.

Some facility types are eligible for participation in Commercial networks only. When applicable, product and network eligibility limitations are identified within the individual facility section.

• When Medicare documentation is identified as required or applicable in a facility section, submit verification for each site, or submit a letter attesting to all covered sites, when applicable.
• A current, one-page Medicare Remittance Advice Summary (RA) from the facility, dated within the past 60 days and with protected health information (PHI) redacted, may be used as verification.
• Facilities applying to the Blue Medicare HMO or Blue Medicare PPO networks must be Medicare certified.

When liability insurance is identified as required in a facility section, submit a current insurance face sheet that includes:

• Facility or provider name.
• Facility address.
• Current coverage dates.
• Coverage limits of at least $1 million per occurrence and $3 million aggregate.
• A letter attesting to all covered sites may be submitted when applicable.

If “Yes” was selected for Question 3 in the Other Information section at the bottom of page 6 of the application, provide:

• The number of cases with amounts less than $200,000.
• For each case with an actual or anticipated amount greater than $200,000: occurrence date, settlement date, and nature of the case.

Required Documentation

• Current North Carolina license
• Proof of Medicare certification

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required, see General Requirements

Accreditation

• Ambulatory infusion agencies must be accredited. Submit the accreditation cover letter and follow-up letter, if applicable.

• Submit one of the following accreditation certificates for each site, or a letter attesting to all covered sites:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required, see General Requirements

Accreditation

• Ambulatory surgical centers must be accredited by one of the following organizations:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

Licensure

• Division of Health Service Regulation license for each site, or a letter attesting to all covered sites

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required for each site, see General Requirements

Network Eligibility

• Blue Cross NC credentials and contracts Birthing Centers for Commercial products only. Birthing Centers are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Accreditation

• Birthing centers must be accredited by one of the following organizations or programs:

  • The Joint Commission (TJC)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Critical Access Certification for hospitals
  • Commission for the Accreditation of Birth Centers

Licensure

• Division of Health Service Regulation license for each site, or a letter attesting to all covered sites, if applicable

Liability Insurance

• Required for each site, see General Requirements

Emergency Coverage Arrangements

• Submit the policy and procedure for coverage arrangements with a participating provider and hospital in the event of an emergency.

Accreditation or Certification

• Dialysis facilities must be accredited or certified by the Centers for Medicare & Medicaid Services (CMS).

• If accredited, submit a certificate from one of the following:

  • The Joint Commission (TJC)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • National Dialysis Accreditation Commission (NDAC)

Licensure and Survey Documentation

• Current Division of Health Service Regulation End-Stage Renal Disease (ESRD) Facility Survey Report

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required, see General Requirements

Additional Clinical and Quality Documentation

• CLIA certification or registration, or American College of Radiology (ACR) documentation, as applicable
• Current Utilization Management Program
• Current Quality Management or Quality Assurance Program
• Current Infection Control Plan, including infection rates and transfers from the dialysis center to acute care centers
• Current list of all services provided at the facility
• One year of quarterly quality-outcome reporting for the K/DOQI indicators

K/DOQI Indicators

• Urea Reduction Ratio (URR): 65%
• Urea Kinetic Modeling (Kt/V): 1.2 Kt/V delivered versus prescribed dose
• Hemoglobin: 11 to 12 grams
• Hematocrit: greater than 33% for premenopausal females and prepubertal patients; 37% for adult males and postmenopausal females
• Albumin: 3.5 to 5.2
• At least 80% of patients must meet the K/DOQI measures

Medicare Documentation

• Required when applicable, see General Requirements

Accreditation or Exemption

• Nonaccredited pharmacies must submit a Medicare exemption letter.

• If no exemption letter is available, submit accreditation from one of the following:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • The Compliance Team, Inc., Exemplary Provider Award Program
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Healthcare Quality Association on Accreditation (HQAA)
  • National Association of Boards of Pharmacy (NABP)
  • National Board of Accreditation for Orthotic Suppliers (NBAOS)
  • American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC)
  • Board of Certification/Accreditation (BOC)

Liability Insurance

• Required for each site, see General Requirements

Network Eligibility

• Blue Cross NC credentials and contracts Facility-Based Crisis Centers for Commercial products only. Facility-Based Crisis Centers are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Application

• Completed application

Accreditation

• Facility-based crisis centers must be accredited for the appropriate services by one of the following:

  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)

Licensure

• North Carolina Department of Health Service Regulation license for Facility-Based Crisis Service for Individuals of All Disability Groups, License .5000

Liability Insurance

• Required. See General Requirements

Network Eligibility

• Blue Medicare HMO and Blue Medicare PPO networks only

Licensure

• North Carolina license or Certificate of Need, if applicable under state or federal regulatory requirements

Accreditation

• Submit accreditation from one of the following:

  • American College of Radiology (ACR)
  • Intersocietal Accreditation Commission (IAC)
  • The Joint Commission (TJC)

Medicare Documentation

• Medicare certification is required, see General Requirements

Liability Insurance

• Required, see General Requirements

Scope

• Includes equipment-only providers and cardiac event monitoring-only providers

Licensure or Permit

• North Carolina Division of Health Service Regulation license, North Carolina Board of Pharmacy Device Dispensing Permit, or North Carolina Board of Pharmacy Device and Medical Equipment Permit, as applicable

Accreditation

• Submit accreditation from one of the following:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • The Compliance Team, Inc., Exemplary Provider Award Program
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Healthcare Quality Association on Accreditation (HQAA)
  • National Association of Boards of Pharmacy (NABP)
  • National Board of Accreditation for Orthotic Suppliers (NBAOS)
  • American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC)
  • Board of Certification/Accreditation (BOC)

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required for each site, see General Requirements

Accreditation

• Home health agencies must be accredited by one of the following. Submit a certificate for each site, or a letter attesting to all covered sites:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)

Contracting Eligibility Requirements

• The agency must provide all of the following services:

  • Skilled nursing visits
  • Speech therapy
  • Physical therapy
  • Home health aide services
  • Occupational therapy
  • Medical social services

Licensure

• Division of Health Service Regulation license for each site

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• This is required. The face sheet must include the practice or provider address, see General Requirements.

Contracting Eligibility Requirements

• The agency must provide all of the following:

  • Pharmacy services
  • Nursing services
  • Supplies

Licensure and Permit

• Division of Health Service Regulation license and Board of Pharmacy Infusion Services Permit for each site

Accreditation

• Home infusion agencies must be accredited. Submit a certificate for each site, or a letter attesting to all covered sites, from one of the following:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required, see General Requirements

Network Eligibility

• Blue Cross NC credentials and contracts Hospice Agencies for Commercial products only. Hospice Agencies are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Accreditation

• Hospice agencies must be accredited. Submit a certificate for each site, or a letter attesting to all covered sites, from one of the following:

  • The Joint Commission (TJC)
  • Accreditation Commission for Health Care (ACHC)
  • Community Health Accreditation Partner (CHAP)

Licensure

• Division of Health Service Regulation license for each site

Liability Insurance

• Required. See General Requirements

Accreditation

• Hospitals must be accredited by one of the following:

  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • The Joint Commission (TJC)
  • DNV Healthcare National Integrated Accreditation for Healthcare Organizations (NIAHO)
  • Center for Improvement in Healthcare Quality (CIHQ)

Licensure

• Division of Health Service Regulation license for each site, or a letter attesting to all covered sites

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required for each site, see General Requirements

Location and Eligibility

• Not eligible for locations outside North Carolina
• For cardiac event monitoring services, participation is limited to Blue Medicare HMO and Blue Medicare PPO networks.

Laboratory Certification

• CLIA Full, Level 3, certification or registration, if applicable

Accreditation

• Submit accreditation from one of the following:

  • College of American Pathologists (CAP)
  • Commission on Office Laboratory Accreditation (COLA)
  • American College of Radiology (ACR)
  • The Joint Commission (TJC)

Medicare Documentation

• Medicare certification is required, see General Requirements

Liability Insurance

• Required, see General Requirements

Licensure

• North Carolina Department of Health Service Regulation license for Day Activity for Individuals of All Disability Groups, License .5400; or Partial Hospitalization for Individuals Who Are Acutely Mentally Ill, License .1100

Accreditation

• The Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF)

Medicare and Insurance

• Medicare documentation is required when applicable. Liability insurance is required, see General Requirements

Network Eligibility

• Blue Cross NC credentials and contracts Medically Monitored Inpatient Withdrawal Management facilities for Commercial products only. These facilities are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Application

• Completed application

Accreditation

• Accreditation for the appropriate services by one of the following:

  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)

Licensure

• North Carolina Department of Health Service Regulation license for Non-Hospital Medical Detoxification for Individuals Who Are Substance Abusers, License .3100 or Inpatient Hospital Treatment for Individuals Who Have Mental Illness or Substance Abuse Disorders, License .6000

Liability Insurance

• Required, see General Requirements

Network Eligibility

• Blue Medicare HMO and Blue Medicare PPO networks only

Accreditation

• Submit one of the following accreditation certificates, if applicable:

  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Council on Accreditation (COA)
  • Community Health Accreditation Partner (CHAP)
  • Continuing Care Accreditation Commission (CCAC)

Licensure

• North Carolina business license

Medicare Documentation

• Required, see General Requirements

Liability Insurance

• Required, see General Requirements

Licensure and Certification

• Division of Health Service Regulation license to provide opioid treatment
• Drug Enforcement Administration (DEA) registration
• Substance Abuse and Mental Health Services Administration (SAMHSA) certification. Provisional certification is not accepted
• Medicare provider number

Medicare Documentation

• Required, see General Requirements

Accreditation

• National accreditation from one of the following:

  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • The Joint Commission (TJC)
  • Council on Accreditation (COA)
  • National Commission on Correctional Health Care (NCCHC)

Liability Insurance

• General and professional liability insurance is required, see General Requirements.

Contracting Eligibility Requirements

• The facility must provide the applicable services below:

  • Methadone treatment
  • Individual psychotherapy
  • Buprenorphine/naloxone treatment
  • Intensive outpatient treatment
  • Family psychotherapy
  • Group psychotherapy
  • Psychiatric evaluation

Scope

• Includes all orthotics and prosthetics, including breast prosthetics-only providers

Accreditation

• Submit accreditation from one of the following:

  • American Board for Certification in Orthotics, Prosthetics, & Pedorthics (ABC)
  • Board of Certification/Accreditation (BOC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Community Health Accreditation Partner (CHAP)
  • Healthcare Quality Association on Accreditation (HQAA)
  • National Association of Boards of Pharmacy (NABP)
  • The Joint Commission (TJC)
  • The Compliance Team, Inc.
  • National Board of Accreditation for Orthotic Suppliers (NBAOS)
  • Accreditation Commission for Health Care (ACHC)

Medicare Documentation

• Required when applicable, see General Requirements

Liability Insurance

• Required, see General Requirements

Licensure

• North Carolina Department of Health Service Regulation license for Substance Abuse Comprehensive Outpatient Treatment, License .4500

Accreditation

• The Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF)

Medicare and Insurance

• Medicare documentation is required when applicable. Liability insurance is required, see General Requirements.

Licensure

• North Carolina Department of Health Service Regulation license for Partial Hospitalization for Individuals Who Are Acutely Mentally Ill, License .1100

Accreditation

• The Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF)

Medicare and Insurance

• Medicare documentation is required when applicable. Liability insurance is required, see General Requirements.

Network Eligibility

• Blue Cross NC credentials and contracts Private Duty Nursing agencies for Commercial products only. Private Duty Nursing agencies are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Accreditation

• Private duty nursing agencies must be accredited. Submit a certificate for each site, or a letter attesting to all covered sites, from one of the following:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)

Licensure

• Division of Health Service Regulation license for each site

Liability Insurance

• Required, see General Requirements

Network Eligibility

• Blue Medicare HMO and Blue Medicare PPO networks only
• For commercial network applications, contact networkteam@avalonhcs.com.

Laboratory Certification

• CLIA Full, Level 3, certificate

Accreditation or Survey

• Submit accreditation from College of American Pathologists (CAP), Commission on Office Laboratory Accreditation (COLA), or The Joint Commission (TJC).
• If the laboratory is not accredited by CAP, COLA, or TJC, submit a CMS site survey.

Medicare Documentation

• Medicare certification is required, see General Requirements.

Liability Insurance

• This is required, see General Requirements.

Network Eligibility

• Blue Cross NC credentials and contracts Residential Treatment Facilities for Commercial products only. Residential Treatment Facilities are not eligible for credentialing or contracting in Blue Medicare HMO or Blue Medicare PPO networks.

Licensure

• North Carolina Department of Health Service Regulation license for Residential Treatment/Rehabilitation for Individuals With Substance Abuse Disorders, License .3400.

Accreditation or Survey

• Accreditation from The Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF); or a current North Carolina State Site Survey/Statement of Deficiencies (SOD).

Insurance

• Liability insurance is required. See General Requirements.

Licensure

• North Carolina Department of Health Service Regulation license for Psychiatric Residential Treatment Facility for Children and Adolescents, License .1900; or Inpatient Hospital Treatment for Individuals Who Have Mental Illness or Substance Abuse Disorders, License .6000.

Accreditation or Survey

• Accreditation from TJC or CARF; or a current North Carolina State Site Survey/Statement of Deficiencies (SOD).

Insurance

• Liability insurance is required. See General Requirements.

Licensure

• North Carolina Department of Health Service Regulation license for Supervised Living for Adults With Mental Illness, License .5600A; or Inpatient Hospital Treatment for Individuals Who Have Mental Illness or Substance Abuse Disorders, License .6000.

Accreditation or Survey

• Accreditation from TJC or CARF; or a current North Carolina State Site Survey/Statement of Deficiencies (SOD).

Insurance

• Liability insurance is required. See General Requirements.

Accreditation or CMS Review

• If the facility is not accredited, submit the most recent CMS review.

DMEPOS Accreditation

• If the facility is qualified and enrolled with the National Supplier Clearinghouse as a Medicare-certified DMEPOS supplier, submit accreditation from one of the following:

  • American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC)
  • Board of Certification/Accreditation (BOC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Community Health Accreditation Partner (CHAP)
  • Healthcare Quality Association on Accreditation (HQAA)
  • National Association of Boards of Pharmacy (NABP)
  • The Joint Commission (TJC)
  • The Compliance Team, Inc.
  • National Board of Accreditation for Orthotic Suppliers (NBAOS)
  • Accreditation Commission for Health Care (ACHC)

Licensure

• Division of Health Service Regulation license

Medicare Documentation

• It's required to submit for each site. You can also submit a letter attesting to all covered sites, see General Requirements.

Liability Insurance

This is required, see General Requirements.

Network Eligibility

• Blue Medicare HMO and Blue Medicare PPO networks only

Medicare Documentation

• Medicare certification is required when applicable, see General Requirements.

Accreditation

• Submit one of the following accreditation certificates, if applicable:

  • The Joint Commission (TJC)
  • Community Health Accreditation Partner (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • International Organization for Standardization (ISO)
  • The Compliance Team, Inc., Exemplary Provider Award Program
  • American Academy of Sleep Medicine (AASM)

Liability Insurance

• This is required, see General Requirements.

Permit

• Board of Pharmacy Device and Medical Equipment Permit

Medicare Documentation

• Medicare certification is required, see General Requirements

Liability Insurance

• Required, see General Requirements

Laboratory Certification

• CLIA certification or registration, if applicable

Accreditation

• URAC accreditation
• In lieu of URAC accreditation, a pharmacy with federal designation as a Hemophilia Treatment Center may be accepted.