BCBS Credentialing: Getting In Network with Blue Cross Blue Shield

More providers ask us about BCBS credentialing than about any other payer, and almost every question comes back to the same misunderstanding. Blue Cross Blue Shield is not a single national company. It is an association of independent, locally operated licensees, around three dozen of them, each with its own network, its own credentialing department, its own fee schedule and its own timetable.

This guide explains what that means in practice. For the work itself, see our medical credentialing services.

One brand, many separate applications

The practical consequences of the federated structure:

• You credential with the plan for your state, not with "BCBS". A provider in Virginia applies to the Virginia licensee; a practice with offices in two states applies twice.
• Being in network in one state does not carry over. There is no national reciprocity for credentialing, even though the card looks the same to the patient.
• Fee schedules differ between licensees for identical codes, sometimes substantially.
• Product lines within one licensee are often separate. Commercial PPO, HMO, Medicare Advantage, Medicaid managed care and the ACA exchange products can each require their own participation election, being in the commercial network does not put you in the exchange network.

BlueCard: why you still see out-of-state members

BlueCard is the program that lets a member of one Blue plan receive care from a provider contracted with another. If you are in network with your local plan, you are generally in network for a visiting member of another Blue plan. You bill your local plan, and it settles with the member's home plan behind the scenes.

This is genuinely useful: one contract gives you access to Blue members nationwide. It also means claims for out-of-state members can take longer and can be adjudicated under the home plan's benefit rules, which is worth knowing before you chase a slow payment.

The process, step by step

Ninety to 120 days end to end is normal. The committee calendar is the part nobody can shorten: miss a meeting by two days and the file waits a month.

Behavioral health with BCBS

Therapists, counselors and psychologists should check who actually owns the behavioral network before applying. Several Blue licensees delegate behavioral health to a separate company Carelon Behavioral Health (formerly Beacon) and Magellan are the ones we see most often, and some plans administer it in house.

An application sent to the medical plan when a delegate owns the behavioral network is not forwarded. It simply does not exist as far as the plan is concerned, and providers frequently wait months before discovering this. Our insurance credentialing for therapists and mental health providers page maps which carve-out owns which product.

What slows a BCBS application down

• A lapsed CAQH attestation. Re-attestation is required every 120 days, and a lapse mid-review stalls the file silently.
• The plan not authorized in CAQH. Completing the profile is not enough; each plan needs access granted.
• Unexplained work-history gaps. Anything over 30 days needs a written explanation, not a blank.
• Address mismatches between the application, the W-9, the license and NPPES.
• A closed panel in your county for your specialty, worth asking about before you file rather than after.

Can you backdate?

Sometimes. Some Blue licensees will backdate the effective date to the application or approval date; many will not. It is worth asking in writing at submission, because the answer decides whether the visits you provide during the wait are billable or written off. We ask on every application as a matter of routine.

Related

• The work itselfMedical credentialing and provider enrollment services
• Therapists and counselorsInsurance credentialing for therapists carve-outs, closed panels and Medicare