Provider credentialing requirements

Practitioners eligible for credentialing

Before reviewing the credentialing requirements, check whether your practitioner type is credentialed by Blue Cross NC. This list can help you quickly confirm eligibility and identify any practitioner-specific requirements that may apply.

• Doctor of Medicine (MD)
• Doctor of Osteopathic Medicine (DO)

• Doctor of Dental Surgery (DDS)
• Doctor of Dental Medicine (DMD)

• Doctor of Podiatric Medicine (DPM)
• Doctor of Optometry (OD)
• Doctor of Chiropractic (DC)
• Hearing Aid Fitter
• Registered Dietician (RD/RDN)

• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Family Nurse Practitioner (FNP)
• Certified Nurse Midwife (CNM)
• Certified Registered Nurse Anesthetist (CRNA)

• Psychologist (PSYD)
• Licensed Psychological Associate (LPA)
• Licensed Clinical Social Worker (LCSW)
• Licensed Clinical Social Worker Associate (LCSWA)
• Licensed Clinical Mental Health Counselor (LCMHC)
• Licensed Clinical Mental Health Counselor Associate (LCMHCA)
• Licensed Marriage and Family Therapist (LMFT)
• Licensed Family and Marriage Therapist Associate (LMFTA)
• Certified Alcohol and Drug Counselor (CADC)
• Licensed Clinical Addiction Specialist (LCAS)
• Pastoral Counselor
• Board Certified Behavior Analyst (BCBA)

• Physical Therapist (PT)
• Occupational Therapist (OT)
• Speech-Language Pathologist (SLP)
• Audiologist

• Pharmacist - Immunizing only

Credentialing exceptions

Credentialing exceptions apply to the following practitioner types:

• Ophthalmology / Optometry: Credentialing and participation for optometrists and ophthalmologists providing routine vision and medical eye care services in all counties is managed exclusively by Community Eye Care (CEC).
• Doctor of Chiropractic (DC): Chiropractors participating in commercial networks are credentialed through the Health Network Solutions (HSN). Chiropractors seeking Blue Cross NC Medicare participation must request credentialing directly through Blue Cross NC.

Requirements for all practitioners

Unless otherwise noted, all practitioners must meet the standard credentialing requirements:

• Maintain a complete CAQH profile with a current signed attestation.
• Complete all required application and disclosure information, including explanations for any disclosure responses that require additional review.
• Hold an active North Carolina professional license applicable to the practitioner’s profession.
• Complete education and training verification appropriate to the practitioner type and specialty.
• Maintain professional liability insurance coverage (Minimum $1 million per occurrence - $3 million aggregate)
• Provide required work history information for initial credentialing, including explanations for gaps greater than 90 days.
• Meet Blue Cross NC screening requirements, including licensure verification, sanctions and exclusion checks, NPDB review, Medicare Opt-Out review, SAM review, and CMS Preclusion review.

Additional requirements for certain practitioner types

Some practitioner types have additional credentialing requirements beyond the standard items listed.

Board certification is required, subject to applicable policy exceptions. Practitioners who do not meet board certification requirements may require Credentialing Committee review. DEA information must be provided as applicable to the practitioner’s scope of practice. Practitioners must provide information regarding clinical privileges, and when privileges are held, they must be in good standing at a Blue Cross NC participating hospital, as applicable.

Board certification is required or the practitioner may be referred for Credentialing Committee review if not board certified. DEA registration is required when applicable.

Advanced practice licensure and certification must be verified. DEA registration may be required based on scope of practice and prescribing authority.

Current BCBA certification must be verified.

Current CPR certification, immunization certificate, and current written immunization protocol are required.

Additional information may be requested

During credentialing review, Blue Cross NC may request additional documentation, explanations, or verification when information is incomplete, documents are expired, disclosure responses require further review, work history gaps require clarification, DEA information is incomplete or not applicable to scope, malpractice documentation is incomplete, or Credentialing Committee review is needed.