Idaho Practitioner Application Form PDF Details

The Idaho Practitioner Application form is an essential document for professionals seeking credentialing with Blue Cross of Idaho, laying out a detailed roadmap for submitting accurate and comprehensive information necessary for the credentialing process. As a comprehensive checklist, it guides applicants through the required steps, from ensuring all sections of the application are filled out thoroughly, to listing professional licenses, providing DEA registration information, and detailing educational backgrounds. Additionally, it emphasizes the importance of accuracy in reporting board certifications, hospital affiliations, work history, and insurance coverage. To avoid delays or rejections, applicants must also include an Idaho Practitioner Attestation Questions Form and a Release of Authorization Form, with all data being current within the last 180 days of the Blue Cross review. The form stipulates clear guidelines for application completion, submission, and offers insights into the rights of applicants regarding credentialing decisions. It underscores the necessity of attention to detail and adherence to provided instructions to ensure a smooth credentialing process. With an average processing time of 60 to 90 days, it advises applicants to allow ample time for review and to contact Blue Cross of Idaho directly for any credentialing queries, ensuring that every applicant is prepared for and informed about every step of the credentialing journey.

QuestionAnswer
Form NameIdaho Practitioner Application Form
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other namesidaho credentialing online, id credentialing, blue cross practitioner, id practitioner

Form Preview Example

Initial Practitioner Credentialing Application Checklist

Thank฀you฀for฀your฀interest฀in฀Blue฀Cross฀of฀Idaho.฀Use฀this฀checklist฀to฀ensure฀proper฀ completion฀of฀the฀enclosed฀Idaho฀Practitioner฀Application฀–฀September฀2014.฀

•฀฀ Completed฀Application:฀Ensure฀all฀sections฀of฀the฀application฀are฀complete฀or฀indicate฀ “Does฀Not฀Apply”฀as฀appropriate.฀Please฀be฀aware฀that฀referencing฀“Curriculum฀Vitae”฀ or฀“CV”฀are฀not฀acceptable฀substitutes฀for฀completing฀the฀application.

•฀ ฀Licenses:฀List฀all฀current฀and฀expired฀state฀professional฀licenses,฀including฀those฀for฀Idaho.฀

(PAGE 2, SECTION V)

•฀฀฀ DEA฀Registration:฀Provide฀DEA฀registration฀information,฀as฀applicable.฀

(PAGE 2, SECTION IV)

•฀฀฀ Education:฀Provide฀education฀information,฀complete฀with฀start฀and฀end฀dates.฀

(PAGES 2-4 SECTION VI, VII, VIII)

•฀฀฀ Certiications:฀Provide฀board฀and฀any฀other฀applicable฀certiication฀information.฀(PAGE 4, SECTION XIV).฀In฀addition,฀nurse฀practitioners฀and฀allied฀health฀practitioners฀must฀provide฀ copies฀of฀professional฀certiications.฀(I.E. AANP, ANCC, CCNA, CRNA ETC.)

•฀฀฀ Hospital฀Afiliations:฀List฀current,฀primary฀admitting฀facility฀along฀with฀other฀current฀or฀ pending฀hospital฀afiliations. (PAGE 5, SECTION XVI)

•฀฀฀ Work฀History:฀Provide฀complete฀work฀history฀and฀explain฀lapses฀for฀the฀previous฀ive฀years฀ or฀since฀earning฀degree.฀(PAGE 6, SECTION XVII)

•฀฀฀ Liability฀Insurance:฀Include฀copy฀of฀current฀professional฀liability฀insurance฀face฀sheet฀ showing฀minimum฀requirements฀of฀$1,000,000/$3,000,000฀in฀coverage.

•฀฀฀ Idaho฀Practitioner฀Attestation฀Questions฀Form:฀Provide฀a฀completed,฀signed,฀dated฀and฀

unaltered฀copy.฀Provide฀written฀explanation฀for฀any฀“Yes”฀answers.฀(pages฀9฀and฀10)

•฀฀฀ Release฀of฀Authorization฀Form:฀Provide฀a฀completed,฀signed,฀dated฀and฀unaltered฀copy.฀

(PAGE 11)

Please฀note:฀Your฀application฀information฀cannot฀be฀more฀than฀180฀days฀old฀at฀the฀time฀of฀ Blue฀Cross฀of฀Idaho฀review.฀On฀average,฀our฀credentialing฀process฀takes฀60฀to฀90฀days.฀Please฀ make฀sure฀you฀provide฀ample฀processing฀time฀when฀signing฀and฀submitting฀your฀application.฀ We฀cannot฀accept฀or฀process฀incomplete฀or฀outdated฀applications.฀Lack฀of฀correct฀information฀ will฀delay฀your฀ability฀to฀contract฀with฀Blue฀Cross฀of฀Idaho.

We฀accept฀applications฀via฀fax฀at฀208-387-6818฀or฀emailed฀to฀PR2PI@BCIDAHO.COM.

For฀credentialing฀questions,฀please฀call฀208-286-3447฀or฀208-472-5112.

(REVISED: 9/2014)

3000฀E.฀Pine฀Avenue,฀Meridian,฀ID฀83642-5995฀•฀P.O.฀Box฀7408,฀Boise,฀ID฀83707-1408฀•฀(208)฀345-4550฀•฀www.bcidaho.com

An Independent Licensee of the Blue Cross and Blue Shield Association

Applicant Rights for Credentialing and Recredentialing

•฀ Applicants฀have฀the฀right,฀upon฀request,฀to฀be฀informed฀of฀the฀status฀of฀their฀application.฀ Applicants฀may฀contact฀credentialing฀staff฀via฀telephone฀or฀in฀writing฀to฀inquire฀as฀to฀the฀ status฀of฀their฀application.

•฀ Credentialing฀staff฀will฀respond฀to฀the฀applicant’s฀request฀for฀information฀either฀via฀ telephone฀or฀in฀writing฀of฀the฀status฀of฀their฀application฀within฀ifteen฀(15)฀calendar฀days.฀ Blue฀Cross฀of฀Idaho฀is฀not฀required฀to฀provide฀the฀applicant฀with฀information฀that฀is฀peer- review฀protected.฀Information฀reported฀to฀the฀National฀Practitioner฀Data฀Bank฀(NPDB)฀is฀ considered฀conidential฀and฀shall฀not฀be฀disclosed.฀An฀applicant฀will฀be฀advised฀that฀they฀ may฀complete฀a฀self-query฀to฀obtain฀information฀that฀is฀contained฀in฀the฀NPDB.

•฀ Applicants฀have฀the฀right฀to฀review฀the฀information฀submitted฀in฀support฀of฀their฀ credentialing฀application.฀This฀review฀is฀at฀the฀applicant’s฀request.

•฀ The฀applicant฀will฀be฀notiied฀in฀writing฀of฀initial฀credentialing฀decisions฀within฀sixty฀ (60)฀days฀of฀being฀reviewed฀for฀credentialing.

•฀ Credentialing฀staff฀will฀notify฀the฀applicant฀in฀writing฀of฀any฀information฀obtained฀during฀

the฀credentialing฀process฀that฀varies฀signiicantly฀from฀the฀information฀provided฀to฀

Blue฀Cross฀by฀the฀applicant.

•฀ Should฀the฀information฀provided฀by฀the฀applicant฀on฀their฀application฀vary฀substantially฀ from฀the฀information฀obtained฀and/or฀provided฀to฀Blue฀Cross฀of฀Idaho฀by฀other฀individuals฀ or฀organizations฀contact฀as฀part฀of฀the฀credentialing฀and/or฀recredentialing฀process,฀ credentialing฀staff฀will฀contact฀the฀applicant฀via฀fax,฀mail฀or฀email฀to฀advise฀the฀applicant฀of฀ the฀variance฀and฀provide฀the฀applicant฀with฀the฀opportunity฀to฀correct฀the฀information฀if฀it฀ is฀erroneous.

•฀ The฀applicant฀will฀submit฀any฀corrections฀in฀writing฀within฀thirty฀(30)฀calendar฀days฀to฀ the฀credentialing฀staff.฀Any฀additional฀documentation฀will฀be฀kept฀as฀part฀of฀the฀applicant’s฀ credential฀ile.

3000฀E.฀Pine฀Avenue,฀Meridian,฀ID฀83642-5995฀•฀P.O.฀Box฀7408,฀Boise,฀ID฀83707-1408฀•฀(208)฀345-4550฀•฀www.bcidaho.com

An Independent Licensee of the Blue Cross and Blue Shield Association

Idaho Practitioner Application

To use the Idaho Practitioner Application (IPA), follow these instructions

Complete the application in its entirety using black or blue ink. Keep an unsigned and undated copy of the application on file for future requests. When a request is received, send a copy of the completed application, making sure that all information is complete, current and accurate. Please sign and date pages 9 , 10, and 11. Please document any YES responses on the Attestation Question page.

Prior to submitting this application to any health care related organization, inquire with the organization, as you may need authorization (through a pre-application process) before the application is accepted. Identify the health care related organization(s) to which this application is being submitted in the space provided below.

Attach copies of requested documents each time the application is submitted.

If changes must be made to the completed application, strike out the information and write in the modification, initial and date.

If a section does not apply to you, please check the provided box at the top of the section.

Expect addendums from the requesting organizations for information not included on the IPA.

This application is submitted to

I. INSTRUCTIONS

II. PRACTITIONER INFORMATION

This form should be typed or legibly printed in black or blue ink. If more space is needed than provided, attach additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the following documents must be submitted

with this application (all are required for MDs, DOs; as applicable for other health practitioners). If not available, indicate why.

∙

State Professional License(s)

∙ Passport photo (for hospitals only)

∙ DEA Certificate w/ Idaho address

∙

Face Sheet of Professional Liability Policy or Certificate

∙

ECFMG (if applicable)

∙

Curriculum Vitae (Not an acceptable substitute for completing

 

∙ ISBP Certificate

 

 

 

 

 

 

 

 

 

 

 

the application.)

 

 

 

 

 

 

 

 

** All sections must be completed in their entirety.**

 

 

 

 

 

 

Last name (include suffix; Jr., Sr., III)

 

 

 

 

 

 

 

First (do not abbreviate)

 

 

 

 

 

Middle (do not abbreviate)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other name(s) under which you have been known by reference, licensing and or educational institutions?

Degree(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home telephone number

 

 

 

 

 

Pager number

 

 

 

Cell number

 

E-mail address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home mailing address

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date

Birth place (city, state, country)

 

 

Social security number

 

 

 

Citizenship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Languages spoken by practitioner

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

Gender

 

 

 

 

 

 

 

 

 

 

 

PCP

Urgent Care

Specialist

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

Medicare UPIN

 

 

Medicare number (ID)

 

 

Medicaid number(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other professional interests in practice, research, etc.

 

Specialty

 

 

 

 

 

 

Subspecialties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. PRACTICE INFORMATION

Effective Date at Primary Practice location __________

Name of practice, affiliation or clinic name

 

 

 

Department name (if hospital based)

 

 

 

 

 

 

Primary office street address

 

City

 

State

Zip code

 

 

 

 

 

 

Patient appointment telephone number

Fax number

 

Name affiliated with tax ID number

Federal tax ID number

 

 

 

 

 

 

Mailing address (if different from above)

 

City

 

State

Zip code

 

 

 

 

 

 

Idaho Practitioner Application –September 2014

Page 1 of 11

Practitioner Name

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

III. PRACTICE INFORMATION (CONTINUED)

Billing address (if different from above)

 

City

State

Zip code

 

 

 

 

 

Office manager / Administrator name

Administration telephone number

Fax number

E-mail address

 

 

 

 

Credentialing contact (if different from above)

Credentialing telephone number

Fax number

E-mail address

 

 

 

 

 

Effective Date at Secondary Practice location

Name of secondary practice, affiliation or clinic name

 

 

 

 

 

 

Department name (if hospital based)

 

 

 

 

 

 

 

 

 

Secondary office street address

 

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

Patient appointment telephone number

Fax number

 

Name affiliated with tax ID

Federal tax ID number

 

 

 

 

 

number

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different from above)

 

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

Billing address (if different from above)

 

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

Office manager / Administrator name

 

Administration telephone number

 

Fax number

E-mail address

 

 

 

 

 

 

 

Credentialing contact (if different from above)

 

Credentialing telephone number

 

 

Fax number

E-mail address

 

 

 

 

 

 

 

 

 

List other office locations with above information on a separate sheet.

PROFESSIONAL

LICENSURE

IV.

 

Idaho State professional license/registration/certificate number

Issue date

Expiration date

 

 

Drug Enforcement Administration (DEA) registration number

State controlled substance certificate number

ECFMG number (applicable to foreign medical graduates)

Status

Active Inactive Temporary

Name of sponsor if required by licensure, (i.e. Physician’s Assistant).

Issue date

 

Expiration date

Issue date

 

Expiration date

 

 

 

 

Date issued

 

 

 

 

POROFESSIONALTHER

LICENSES

 

State

 

 

Expiration date

 

 

 

 

 

 

 

 

State

 

 

 

 

Expiration date

 

ALL

 

 

State

 

 

 

 

 

V.

 

 

Expiration date

 

 

 

 

 

-UGRADUATENDER

EDUCATION

 

Name of college or university

 

 

 

 

 

 

Degree received

 

 

 

 

 

 

 

 

Mailing address

 

 

 

 

 

 

 

 

Name of college or university

 

 

 

 

Degree received

 

VI.

 

 

Mailing address

 

 

 

 

 

Idaho Practitioner Application –September 2014

License/registration/certificate number

 

Date Issued

 

 

 

 

 

Year relinquished

Reason

 

 

 

 

License/registration/certificate number

 

Date Issued

 

 

 

 

 

Year relinquished

Reason

 

 

 

 

License/registration/certificate number

 

Date Issued

 

 

 

 

 

Year relinquished

Reason

 

 

 

 

 

 

 

 

 

 

Does Not Apply

 

 

 

 

Graduation date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

Zip code

 

 

 

 

Graduation date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

Zip code

 

 

 

 

 

 

 

 

Page 2 of 11

Practitioner Name

 

 

 

 

 

Modification to the wording or format of the Idaho Practitioner Application may invalidate the application.

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