| Credentialing forms
| Form |
Description |
Instructions |
Practitioner
credentialing criteria (PDF)
(effective 11/1/2007)
Organization
credentialing criteria (PDF)
(effective 11/1/2007)
|
This document explains our organizational requirements for
requesting participation and continued participation with Regence BlueCross BlueShield of Oregon.
All practitioners and organizational providers must complete an application
for participation so we may perform a comprehensive review of the provider's
credentials. Once the application is completed, we will begin a review of
the practitioners or organizational credentials using a variety of national
and state data sources. |
|
Oregon Practitioner Credentialing Application (MS Word format)
If you don't have MS Word, download the free Word View 2003 program here. |
This form must be completed to begin the process of credentialing. |
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Complete the form in its entirety using black or blue ink. |
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If a particular question does not pertain to you or your practice,
please check the box at the tops of that section. |
|
Keep an unsigned and undated copy in your files for any future requests,
if necessary. |
|
Attach copies of requested documents. |
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If changes are made to the completed application, strike out the
information and write in the modification, initial and date. |
|
Document any ‘YES’ responses on the Attestation Question
page. |
|
Expect addendum’s from the requesting organizations for information
not included on this form. |
|
Fax your completed application to our Credentialing Department at (503) 225-4808, or mail it to Credentialing, Regence BCBSO, PO Box 1271 MS E9B, Portland, Oregon 97207-1271. |
|
Universal
Facility Application (PDF) |
This form must be completed to begin the process of credentialing. |
|
Complete the form in its entirety using black or blue ink. |
|
Indicate if initial credentialing or recredentialing |
|
Attach copies of requested documents |
|
If a question does not apply to your facility, answer with ‘Not-Applicable’
or ‘N/A’. |
|
If additional space is necessary to provide answers, attach additional
sheet(s) of paper. |
|
Keep an unsigned and undated copy in your files for any future request,
if necessary. |
|
Application must be signed and dated where indicated. |
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Mail your completed application to our Credentialing Department at P.O. Box 21267, Mail Stop S555, Seattle WA 98111-3267 |
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Regence BCBSO credentialing and contracting process
Your credentialing application must be completed and approved before contracting can begin. Your provider relations representative can give you detailed information about credentialing and contracting. The list below contains the steps involved in our credentialing and contracting processes.
- Physicians and other health care professionals who wish to contract with Regence must successfully complete our credentialing process.
- A standard Oregon Practitioner Credentialing Application is available from The Office for Oregon Health Policy & Research. Please fax your completed application to our Credentialing Department at (503) 225-4808, or mail it to Credentialing, Regence BCBSO, PO Box 1271 MS E9B, Portland, Oregon 97207-1271.
- One set of each agreement for which you are eligible and have requested from your provider relations representative will be mailed to you within seven working days of the credentialing committee meeting.
- Return all signed and dated provider agreements immediately after receiving them.
- The effective date of the provider's participation with Regence BCBSO will be the first day of the month that we receive the signed agreements, and the credentialing process has been completed.
- Delays in returning your signed provider agreements will impact your effective date.
- One signed copy of each provider agreement will be returned to you along with your effective date(s) of participation and assigned provider number(s).
A complete credentialing application includes the following items:
- State Professional License(s)
- Drug Enforcement Administration (DEA) Certificate
- Educational Commission for Foreign Medical Graduates (ECFMG)
- Face sheet of Professional Liability Policy or Certificate of Insurance
Please note: Physicians or other health care professionals contracted through a Medical Group Agreement must complete credentialing, although provider agreements need not be requested or returned by individual providers.
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