Did you know that Blue Cross Blue Shield, or BCBS for short, provides health insurance coverage to nearly six million enrollees in New York State (NYS)? This number accounts for one-third of all New Yorkers.
Thus, if you are a healthcare provider already practicing or planning on moving to New York, you must get credentialed with BCBS to expand your patient base.
This guide covers everything you need to know to ensure successful BCBS credentialing in NYS, from application requirements to key challenges and best practices. So, continue reading!
BCBS NY Provider Enrollment & Credentialing Requirements
In this guide, we will discuss the BCBS credentialing requirements for Anthem (formerly Empire) and Excellus. The reason? Both are independent licensees of the overarching Blue Cross Blue Shield Association. However, they are distinct companies that operate in entirely different geographic regions of New York State.
- Excellus Blue Cross Blue Shield is a local, regional non-profit organization that specifically manages coverage across upstate and central New York.
- Anthem Blue Cross is a multi-state commercial corporation that handles the southeastern portion of New York State, including New York City and Long Island.
So, here we go!
Anthem Blue Cross Blue Shield New York
Have you been eyeing Anthem for getting credentialed with BCBS New York? If yes, note that it uses an online application process combined with the DataSpring, formerly known as the Council for Affordable Quality Healthcare (CAQH) platform, to evaluate licensed independent providers. Besides, the process typically takes around 45 days from the time the credentialing department at Anthem receives the completed application.
Note: Anthem re-credentials network providers every 3 years.
Anthem BCBS New York Credentialing Requirements
The table below offers an at-a-glance view of the Anthem credentialing requirements:
| What Is Needed? | Why Is It Needed? |
|---|---|
| DataSpring Profile | Your DataSpring provider profile should be complete with a status of ‘Initial Application Complete’ or ‘Reattestation’. Besides, you must explicitly grant Anthem permission to access it. |
| Active State License | A current, valid license to practice in each state where you intend to provide services to Anthem members. That is, in this case, you need a license to practice in NYS. |
| 5-Year Work History | A comprehensive resume outlining the last 5 consecutive years in strict month-and-year format. Also, you must explain any gaps in practice. |
| Professional Liability Insurance | A copy of the current malpractice insurance certificate demonstrating active, continuous coverage. |
| IRS Form W-9 | A signed, current W-9 form matching the Tax ID (EIN) or Social Security Number (SSN) used for your business billing. |
| DEA/CDS Certificate | Current Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certificate for New York State (applicable if you prescribe controlled substances). |
| Hospital Privileges | Documentation verifying current, active clinical privileges at an accredited hospital (if applicable to your specialty). |
| Education & Training | Proof of your degrees and training supporting your specialty. You are eligible to apply for the BCBS credentialing application with Anthem even if you are within 60 days of completing your residency. |
| Site Review Consent | Agreement to allow Anthem to perform a physical clinic site review within 30 days of their request if your provider type requires it. |
Excellus Blue Cross Blue Shield New York
Excellus handles its own regional credentialing for counties spanning across Rochester, Central NY, Utica, and the Southern Tier.
In addition, all requests for getting credentialed with BCBS in New York through Excellus are processed within 60 days from the date when Excellus receives a completed application packet.
Note: Similar to Anthem, Excellus also requires providers to re-credential every 3 years.
Excellus BCBS New York Credentialing Requirements
The following table lists the key credentialing application requirements for Excellus BCBS:
| What Is Needed? | Why Is It Needed? |
|---|---|
| Excellus Enrollment Form | A completed, signed application for practitioner enrollment. Note that you must fill in all fields, including your individual NPI, SSN, and taxonomy codes. |
| DataSpring Profile | You must have an active DataSpring Provider ID. That is, you must have completely updated or reattested your profile within the last 90 days. Also, do not forget to authorize access to Excellus. |
| Malpractice Insurance Limits | Proof of active professional liability insurance with minimum coverage amounts of $1 million per occurrence and $3 million aggregate. |
| Active State License | A current, valid license to practice in New York State is needed to start rendering services to Excellus BCBS beneficiaries. |
| Professional Liability Insurance | Attach a copy of the current malpractice insurance certificate demonstrating active, continuous coverage. |
| IRS Form W-9 | You need a signed, current W-9 form matching the tax ID or SSN used for your business billing. |
| DEA/CDS Certificate | DEA or CDS certificate for each New York State is also required (applicable if you prescribe controlled substances). |
| Hospital Privileges | Documentation verifying current, active clinical privileges at an accredited hospital (if applicable to your specialty). |
| Education & Training | All educational and training certificates. Also, note that you can still apply for credentialing with BCBS New York through Excellus if you have 90 days to complete your residency. |
Blue Cross Blue Shield NY Credentialing Application Guidelines
Discussed below are some of the practices you should follow to avoid stalling your BCBS provider credentialing application. Besides, this applies regardless of whether you want enrollment with Blue Cross Blue Shield New York in the upstate, central (Anthem), or southeastern region (Excellus).
1. Audit Your DataSpring Profile
Never start the BCBS New York credentialing application until your DataSpring or CAQH profile is 100% complete.
If you are applying through Excellus, ensure that the last attestation date is within 90 days.
Additionally, do not forget to log in to the portal and check the permission settings. The reason? If you forget to explicitly authorize Anthem or Excellus to access your profile, the respective entity will not be able to retrieve your data, and your application will sit idle.
2. Justify the Work Gaps
Do you want your BCBS New York credentialing application status to turn ‘Approved’? Then you must provide a complete, uninterrupted 5-year employment history formatted specifically as MM/YYYY.
Thus, in case you took a gap to move to another state or continue your education, list that time frame with the reason to prevent the application from being flagged as incomplete.
3. Verify Malpractice Face Sheet
Another key BCBS New York credentialing requirement is to ensure your professional liability insurance certificate is current. Besides, it must list your name, expiration date, and coverage amounts.
4. Cross-Check Your Demographics
Always ensure that the tax ID, group NPI, and legal business name on your signed IRS Form W-9 are perfectly aligned with the practice information entered into CAQH and the local BCBS digital portals.
The reason? Any mismatches in these details can lead to an automatic BCBS credentialing application rejection.
5. Respond to Payer Outreaches Proactively
When the credentialing team contacts you requesting clarification, reply immediately. Note that unanswered inquiries often result in the automatic administrative withdrawal of your application.
Key Challenges in Getting Credentialed with BCBS in New York
Listed below are some of the key challenges healthcare practitioners encounter while trying to complete BCBS New York credentialing and enrollment:
- In NYS, certain regions are highly saturated, and Excellus/Anthem frequently close panels to specific specialties. This means your BCBS New York credentialing application may be put on an indefinite hold even if it is complete and error-free.
- Healthcare providers, given their busy schedules, often forget to re-attest the DataSpring/CAQH profile. However, this can be costly. That is, if your profile is not actively re-attested every 90 days, the review process hits a hard pause.
- If the physical address, group NPI, or Tax ID on your IRS Form W-9 differs from the details listed on your CAQH provider profile or the carrier portal, the system flags your BCBS credentialing application.
- You must adhere to the strict NYS conversion therapy attestations. For example, missing the mandatory page-5 behavioral health conversion therapy clause required by Excellus instantly moves applications out of the review queue.
Fast-Track BCBS New York Credentialing with NeuraBill
With that said, it is time to conclude. If you want to get credentialed with BCBS in New York, you must first understand who to approach, i.e., Anthem or Excellus. Once you know your target, you can start your NY State BCBS provider enrollment and credentialing process in accordance with this guide.
However, if you do not have the time or resources to do it on your own, do not shy away from asking for a professional’s help. NeuraBill is trusted by healthcare practices nationwide. Acquire insurance credentialing services from our experts to accelerate the process.
