physician enrollment - what are the documents required? Physicians and Ancillary Professional Providers

Physicians and individual ancillary professional providers (excludes ancillary facilities) can also electronically submit or update provider application data directly through the CAQH website at www.CAQH.org/cred. For more information on CAQH, call the CAQH Helpdesk at (888) 599-1771.

Based on the type of services performed by the provider, the appropriate documentation will need to be provided before the Agreement may become effective. While the specific information required is subject to the discretion of BCBSF and may vary depending upon provider type, the following is a list of the type of information that may be required:

Completed credentialing application

Signed attestation statement

Copy of Florida license(s)

Copy of Florida registration Education and training, if applicable

Work history for the past five years

Copy of specialty board certificate (if applicable)

Hospital admitting privileges

Current certification of insurance (face sheet with expiration date and coverage amounts)

Explanations for malpractice history and disciplinary actions

Copy of Health and Rehabilitative Services (HRS) and/or Medicare site survey

Copy of Medicare certification(s)

Copy of applicable certification(s)/accreditation(s)

Supervising physician statement (if applicable)

Copy of facility medical director’s curriculum vitae, medical license, DEA certificate

List of procedures performed and/or services rendered (if applicable)

Copy of Quality Improvement Program (if applicable)

Any such information is reviewed and attempts are made to verify certain information using available third party sources. BCBSF queries the National Practitioner Data Bank (NPDB) or Healthcare Integrity and Protection Data Bank (HIPDB) as part of the credentialing process.