Fillable Practitioner Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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Practitioner Recredentialing Application (Blue Cross Blue Shield of North Dakota)

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The Practitioner Recredentialing Application (Blue Cross Blue Shield of North Dakota) form is 6 pages long and contains:

  • 1 signature
  • 98 check-boxes
  • 146 other fields

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File type: PDF

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Page 1 of 6
29380110 • 5-20
Instructions: Recredentialing is conducted every 3 years. Once this application has been submitted, unless you hear otherwise,
your continued participation obligations have been met. Read all instructions carefully prior to submitting your application.
If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.
Section 1: Personal Information (Note: BCBSND may use this method for application follow-up)
Name (Do not use nicknames or initials, unless they are part of your legal name)
Last Name First Name Middle Name Sux
Credential National Provider Identication (NPI) Number
Have you ever used another name?
Yes
No
If yes, please list all other names used and their dates of use Dates other name was used
Other Last Name Other First Name Date Started End Date
Email Phone Fax
Section 2: Practice Location and Specialty Information
IMPORTANT: Include a copy of your W-9 if your Tax ID or practice name has changed from what was submitted previously.
If you have moved or changed employment, complete the Supplemental Additional Location form. Claims may be impacted
if this information is not communicated.
Provide either an individual SSN or Group/Federal Tax ID for your primary practice
Individual Tax ID (SSN) (XXX-XX-XXXX) Group/Federal Tax ID (XX-XXXXXXX)
Use:
Individual
Group
Billing NPI that is Submitted on Claims Name of Practice
Primary Practicing Specialty at this Location
Board certied specialty?
Yes
N
o
Name of Certication Board
Initial Certication Date (MM/DD/YYYY) Recertication Date (MM/DD/YYYY) Expiration Date (MM/DD/YYYY)
Group/Corporate Legal Name as it Appears on W-9
Section 3: Professional IDs
Include all state licenses, DEA Registrations and SAMHSA waivers.
IMPORTANT: DEA registration should match the state in which you work. Provide all current and previous licenses/certications.
Federal DEA Number
N/A
SAMHSA DEA Number State of Registration
DEA Issue Date (MM/DD/YYYY) DEA Expiration Date (MM/DD/YYYY)
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Practitioner Recredentialing Application
Page 2 of 6
29380110 • 5-20
Section 3: Professional IDs (Continued)
License Number License Issuing State
License Issue Date (MM/DD/YYYY) License Expiration Date (MM/DD/YYYY)
Are you currently practicing in this state?
Yes
No
License Number License Issuing State
License Issue Date (MM/DD/YYYY) License Expiration Date (MM/DD/YYYY)
Are you currently practicing in this state?
Yes
No
License Number License Issuing State
License Issue Date (MM/DD/YYYY) License Expiration Date (MM/DD/YYYY)
Are you currently practicing in this state?
Yes
No
Other ID Numbers (Note: Healthy Steps providers must be enrolled with Medicaid)
Are you a participating Medicare provider?
Yes
No
Medicare Number
Are you a participating Medicaid provider?
Yes
No
Medicaid Number Medicaid State
Section 4: Credentialing Contact Information
Application Completed by (Name)
Credentialing Contact Name (If Dierent Than Above)
Mailing Address for Credentialing Correspondence
Street City State Zip
Email Phone Fax
Section 5: Professional Liability/Malpractice Insurance Carrier
Attach a current copy of malpractice/liability insurance certicate which includes the following: practitioner name, policy name,
policy number, coverage dates, coverage amounts. Credentialing application cannot be processed without this attachment.
Section 6: Disclosure Questions Pertaining to Only the Past 3 Years
Answer all questions. For any “Yes” response, provide an explanation on the supplemental Disclosure Question Explanation
Form in Section 8. If question does not apply, answer “No.”
1
Has your license or certication to practice in any jurisdiction been limited, restricted, revoked,
suspended, voluntarily relinquished, terminated, subjected to disciplinary action or otherwise
acted upon in an adverse manner?
Yes
No
2
Have you been sanctioned or penalized by any hospital, licensing board, government entity
or managed care organization?
Yes
No
3 Have you voluntarily or involuntarily refused or denied membership on a hospital medical sta?
Yes
No
4
Have your specic clinical privileges at a facility in any jurisdiction ever been denied, limited,
suspended, diminished, revoked, withdrawn or denied renewal?
Yes
No
5 Have you been subjected to disciplinary action by any medical organization?
Yes
No
6 Have you been subjected to any claim(s) or under investigation for unethical conduct?
Yes
No
7 Has your DEA license or narcotics registration ever been suspended or revoked?
Yes
No
Page 3 of 6
29380110 • 5-20
Section 6: Disclosure Questions Pertaining to Only the Past 3 Years (Continued)
Answer all questions. For any “Yes” response, provide an explanation on the supplemental Disclosure Question Explanation
Form in Section 8. If question does not apply, answer “No.”
8
Have you been the subject of a malpractice claim or are there currently pending malpractice claims,
suits, settlements, arbitration proceedings, or complaints led involving your professional practice?
Yes
No
9 Have any judgments been made against you or settlements by you in any malpractice claim?
Yes
No
10
Have you been denied liability insurance, in whole or in part, or has your policy been canceled,
involuntarily restricted, denied renewal, or rated up because of the nature of volume of claims
against you?
Yes
No
11 Has your employer changed in the past 3 years?
Yes
No
12
Has your board status changed in the past 3 years?
If yes, list specialty:
1st Specialty ____________________________________________________________________________________________
2nd Specialty ____________________________________________________________________________________________
Yes
No
13 Have you been convicted of a felony, fraud, narcotics oense, moral, or any other type of ethical crime?
Yes
No
Section 7: Supplemental Form – Disclosure Question Details
Disclosure Questions answered “Yes” require additional information for review during the Recredentialing process. Please
provide the question number along with as much detail as possible or attach documentation.
Section 8: Patient Population Served
Please Identify The Age Range And Gender Of Patients Served (Check all that apply)
Preschool 0-5
Children 6-12
Adolescent 13-17
Adults 18-65
Geriatrics 65+
Male Patients
Female Patients
Is provider currently accepting new patients?
Yes
No
Page 4 of 6
29380110 • 5-20
Section 9: Behavioral Health Providers Capability/Services
Please check those capabilities in which you are certied or have received specic or on-going training. These may
or may not be a covered benet.
ADD/ADHD
Addictions
Adoption Issues
Anger Management
Anxiety Disorder
Applied Behavior Analysis
Asperger’s Syndrome
Autism
Behavior Modication
Bi-Polar Disorder
Biofeedback
Child Abuse
Christian Counseling
Chronic Mental Illness
Chronic Physical Illness
Co-Dependency
Cognitive Behavioral Therapy
Compulsive Gambling
Conduct/Disruptive Disorders
Couples/Marriage Therapy
Crisis Diversionary Services
Crisis Intervention Services
Critical Incident Debrieng
Depressive Disorder
Developmental Disabilities
Dialectical Behavioral Therapy
Disability Evaluation
Dissociative Disorder
Divorce
Domestic Violence
Dual Diagnosis
Eating Disorders
Electro-Convulsive Therapy (ECT)
Faith Based Counseling
Family Therapy
Forensic/Sex Oenders
Gay/Lesbian Identied Children
Grief Counseling
Group Therapy
Head Injury Patients
Hearing Impaired Issues
HIV Positive/AIDS Patients
Home Care/Home Visits
Hypnosis
Independent Qualied/Medical Ex
Infertility
Inpatient Therapy
Learning Disabilities
Medical Stress/Behavioral Med
Medication Management
Men’s Issues
Mood Disorders
Multicultural Issues
Neuropsych Assessment
Nursing Home Visits
Obesity Assessment/Counseling
Obsessive Compulsive Disorder
Organic Brain Syndrome
Pain Management
Panic Disorder
Parenting Skills
Pastoral Counseling
Personality Disorder
Pervasive Development Disorders
Phobias
Physical Abuse/Violence
Physically Impaired Patients
Play Therapy
Police Personnel
Post Partum Depression
Post Traumatic Stress Disorder
Psych. Disability Eval/Mgmt
Psychological Testing
Psychosomatic
Psychotic Disorders
Rape Issues
Rape Victims
Schizophrenic Disorders
Sex Oender
Sexual Abuse/Violence
Sexual Dysfunction
Sexual Harassment
Sexual Identity Issues
Sleep Disorders
Somatoform Disorders
Substance Abuse
Terminally Ill Patients
Visually Impaired Patients
Weapons Clearance
Women’s Issues
Section 10: Malpractice/Liability Insurance
Attach A Copy Of Malpractice/Liability Insurance Face Sheet.
Attach the malpractice insurance face sheet and evidence (e.g. roster, letter, fax) that clearly states the name of provider being
credentialed and covered under your insurance policy. The face sheet must also contain the name of insurance company, from
and through dates, policy number and occurrence/aggregate coverage amounts.
Page 5 of 6
29380110 • 5-20
Section 11: Consent to the Inspection of Records and Documents Release of Information
and Liability Certication/Attestation
I, (print name) hereby authorize BLUE CROSS BLUE SHIELD
OF NORTH DAKOTA (BCBSND), its professional sta and legal representatives, to contact and consult with administrators
and members of the professional sta of any treatment facility, institution, professional society, school, employer, law
enforcement agency, or practice with which I have been associated, for the purpose of evaluating my professional competence,
character, criminal history and ethical conduct. In addition, I consent to the inspection of all records and documents, including
health records at other treatment facilities that may be material for evaluation of my professional qualications by BCBSND,
its professional sta and legal representatives. I release from liability all individuals or organizations for acts performed in
good faith and without malice honestly initiated and in response to the inquiries authorized for use by BCBSND. I agree
that a photocopy of this authorization may be accepted with the same authority as the original.
I certify and attest to the fact that all of the information I have submitted in this application is true and accurate to the best
of my knowledge and belief.
Signature Date (MM/DD/YYYY)
If you are having diculty submitting the form once completed, please send using one
of the following methods:
• Email:
– Click on “File” at the top of your screen
– Click on “Save As”
– Save the completed form on your computer
– Attach the completed form to an email and send to providerforms@bcbsnd.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave. S.
Fargo, ND 58121
Please double check that the application is complete.
Supplemental Additional Location Form on next page.
SUBMIT FORM
click to sign
signature
click to edit
Page 6 of 6
29380110 • 5-20
Supplemental form to Practitioner Recredentialing Application. This form is not to be used to replace any other documentation.
Provider Information
Provider Name NPI
Specialties
Additional Location Information
Business/Corporation Name Organization NPI
Practicing Address Billing/Mailing Address (If dierent from practicing address)
Street Street
City State Zip City State Zip
Is this the Primary Practice Location for this Provider?
Yes
No
Should this provider display in the directory?
Yes
No
Accepting new patients?
Yes
No
Patient Appointment Phone # Clinic Telephone # Provider Phone # (If dierent from clinic)
Tax Identication Number (TIN) Eective Date
Additional Location Information
Business/Corporation Name Organization NPI
Practicing Address Billing/Mailing Address (If dierent from practicing address)
Street Street
City State Zip City State Zip
Is this the Primary Practice Location for this Provider?
Yes
No
Should this provider display in the directory?
Yes
No
Accepting new patients?
Yes
No
Patient Appointment Phone # Clinic Telephone # Provider Phone # (If dierent from clinic)
Tax Identication Number (TIN) Eective Date
Supplemental Additional Location Form
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Completed 10 June 2021

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