The Idaho Practitioner Application form is a comprehensive document used by healthcare professionals seeking to be credentialed or recredentialed with Blue Cross of Idaho. It lays out specific requirements ranging from personal information, educational background, to professional certifications and affiliations. Ensuring all parts of the application are accurately completed and current is crucial, as incomplete or outdated applications are not accepted. Before diving into the application process, read on to understand each step needed to successfully submit your application. By clicking the button below, get started on filling out your form.
In today's healthcare sector, the process of credentialing practitioners is pivotal for maintaining the quality and integrity of medical services. The Idaho Practitioner Application form serves as a comprehensive tool for this process, crafted to streamline the authentication of qualifications, allowing practitioners to join the esteemed roster of healthcare providers under Blue Cross of Idaho. This detailed document covers a plethora of vital information, from basic identification and contact details to the nitty-gritty of professional experiences, educational background, licensure, certifications, DEA registration, and affiliations. Furthermore, it requires the disclosure of past work history, a testament to the applicant's endurance and commitment to the medical field, alongside a clear display of current professional liability insurance details, ensuring a minimum safeguard of $1,000,000/$3,000,000 in coverage. The form also mandates the completion of the Idaho Practitioner Attestation Questions Form and the Release of Authorization Form, ensuring all provided information is accurate and legally acknowledged by the applicant. Moreover, to simplify the cross-verification task for Blue Cross of Idaho, the form highlights the necessity of affixing various essential documents and adheres to a strict submission timeline, thereby refining the entire credentialing journey. Accompanied by the rights extended to applicants regarding the status inquiries and the thorough review of submitted credentials, the design of this form encapsulates a balanced approach towards credentialing, encapsulating a rigorous yet facilitative pathway for practitioners aiming to deliver healthcare services in Idaho.
Initial Practitioner Credentialing Application Checklist
ThankyouforyourinterestinBlueCrossofIdaho.Usethischecklisttoensureproper completionoftheenclosedIdahoPractitionerApplication–September2014.
• CompletedApplication:Ensureallsectionsoftheapplicationarecompleteorindicate “DoesNotApply”asappropriate.Pleasebeawarethatreferencing“CurriculumVitae” or“CV”arenotacceptablesubstitutesforcompletingtheapplication.
• Licenses: Listallcurrentandexpiredstateprofessionallicenses,includingthoseforIdaho.
(PAGE 2, SECTION V)
• DEARegistration:ProvideDEAregistrationinformation,asapplicable.
(PAGE 2, SECTION IV)
• Education:Provideeducationinformation,completewithstartandenddates.
(PAGES 2-4 SECTION VI, VII, VIII)
• Certiications:Provideboardandanyotherapplicablecertiicationinformation.(PAGE 4, SECTION XIV).Inaddition,nursepractitionersandalliedhealthpractitionersmustprovide copiesofprofessionalcertiications.(I.E. AANP, ANCC, CCNA, CRNA ETC.)
• HospitalAfiliations:Listcurrent,primaryadmittingfacilityalongwithothercurrentor pendinghospitalafiliations. (PAGE 5, SECTION XVI)
• WorkHistory:Providecompleteworkhistoryandexplainlapsesforthepreviousiveyears orsinceearningdegree.(PAGE 6, SECTION XVII)
• LiabilityInsurance:Includecopyofcurrentprofessionalliabilityinsurancefacesheet showingminimumrequirementsof$1,000,000/$3,000,000incoverage.
• IdahoPractitionerAttestationQuestionsForm:Provideacompleted,signed,datedand
unalteredcopy.Providewrittenexplanationforany“Yes”answers.(pages9and10)
• ReleaseofAuthorizationForm:Provideacompleted,signed,datedandunalteredcopy.
(PAGE 11)
Pleasenote:Yourapplicationinformationcannotbemorethan180daysoldatthetimeof BlueCrossofIdahoreview.Onaverage,ourcredentialingprocesstakes60to90days.Please makesureyouprovideampleprocessingtimewhensigningandsubmittingyourapplication. Wecannotacceptorprocessincompleteoroutdatedapplications.Lackofcorrectinformation willdelayyourabilitytocontractwithBlueCrossofIdaho.
Weacceptapplicationsviafaxat208-387-6818oremailedtoPR2PI@BCIDAHO.COM.
Forcredentialingquestions,pleasecall208-286-3447or208-472-5112.
(REVISED: 9/2014)
3000E.PineAvenue,Meridian,ID83642-5995•P.O.Box7408,Boise,ID83707-1408•(208)345-4550•www.bcidaho.com
An Independent Licensee of the Blue Cross and Blue Shield Association
Applicant Rights for Credentialing and Recredentialing
• Applicantshavetheright,uponrequest,tobeinformedofthestatusoftheirapplication. Applicantsmaycontactcredentialingstaffviatelephoneorinwritingtoinquireastothe statusoftheirapplication.
• Credentialingstaffwillrespondtotheapplicant’srequestforinformationeithervia telephoneorinwritingofthestatusoftheirapplicationwithinifteen(15)calendardays. BlueCrossofIdahoisnotrequiredtoprovidetheapplicantwithinformationthatispeer- reviewprotected.InformationreportedtotheNationalPractitionerDataBank(NPDB)is consideredconidentialandshallnotbedisclosed.Anapplicantwillbeadvisedthatthey maycompleteaself-querytoobtaininformationthatiscontainedintheNPDB.
• Applicantshavetherighttoreviewtheinformationsubmittedinsupportoftheir credentialingapplication.Thisreviewisattheapplicant’srequest.
• Theapplicantwillbenotiiedinwritingofinitialcredentialingdecisionswithinsixty (60)daysofbeingreviewedforcredentialing.
• Credentialingstaffwillnotifytheapplicantinwritingofanyinformationobtainedduring
thecredentialingprocessthatvariessigniicantlyfromtheinformationprovidedto
BlueCrossbytheapplicant.
• Shouldtheinformationprovidedbytheapplicantontheirapplicationvarysubstantially fromtheinformationobtainedand/orprovidedtoBlueCrossofIdahobyotherindividuals ororganizationscontactaspartofthecredentialingand/orrecredentialingprocess, credentialingstaffwillcontacttheapplicantviafax,mailoremailtoadvisetheapplicantof thevarianceandprovidetheapplicantwiththeopportunitytocorrecttheinformationifit iserroneous.
• Theapplicantwillsubmitanycorrectionsinwritingwithinthirty(30)calendardaysto thecredentialingstaff.Anyadditionaldocumentationwillbekeptaspartoftheapplicant’s credentialile.
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.
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
Patient appointment telephone number
Fax number
Name affiliated with tax ID number
Federal tax ID number
Mailing address (if different from above)
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)
Office manager / Administrator name
Administration telephone number
Credentialing contact (if different from above)
Credentialing telephone number
Effective Date at Secondary Practice location
Name of secondary practice, affiliation or clinic name
Secondary office street address
Name affiliated with tax ID
number
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).
Date issued
POROFESSIONALTHER
LICENSES
ALL
V.
-UGRADUATENDER
EDUCATION
Name of college or university
Degree received
Mailing address
VI.
License/registration/certificate number
Date Issued
Year relinquished
Reason
Does Not Apply
Graduation date
Page 2 of 11
(Do not abbreviate) (Attach additional sheet if necessary)
MEDICAL/PROFESSIONAL
VII.
Medical/Professional school
Start date
Medical/Professional School
Phone
Fax
Institution
GVIII.RADUATE EDUCATION
Program or course of study
Faculty director
Dates attended
(
/
) - (
)
/PGYINTERNSHIP
Program director
Completion date
IX. I
Type of internship
Did you successfully complete the program?
Yes
No
(If "No", please explain on separate sheet.)
ESIDENCIES
Type of residency
R
X.
Page 3 of 11
Course of study
XI. FELLOWSHIPS
XII. PRECEPTORSHIP
Department chairman
Training
XIII. FACULTY
APPOINTMENT
Position
XIV. BOARD CERTIFICATION
Are you board or otherwise professionally certified?
Yes If "Yes", please complete below
No If "No", describe your intent for certification, if any, and dates of
testing for Certification on separate sheet.
Issuing Board/Entity
Date
Expiration Date
Issued
Certified
Recertified
(if any)
Have you applied for certification other than those indicated above?
If so, list certification and date
If you participate in a specialty which does not have board certification, please indicate specialty
Page 4 of 11 Practitioner Name
ACLS, BLS, ATLS, PALS, NRP, NALS
(i.e., Fluoroscopy, Radiography, etc. – Attach certificate if applicable)
OXV.THER ERTIFICATIONSC
Type
Number
XVI.
Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) have current
HOSPITAL AND
affiliations, (B) applications in process, (C) have had previous affiliations or, if no current affiliation, (D) have a current
OTHER
coverage plan. This includes hospitals, surgery centers, institutions, corporations, military assignments, or government
INSTITUTIONAL
agencies. If more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII,
AFFILIATIONS
Work History.
A. CURRENT AFFILIATIONS
Name of primary facility
(Do you have admitting privileges?
No)
Department
Department / Clinical Chair
Status (active, provisional, courtesy, temporary, etc.)
Phone number
Appointment date
Name of secondary facility
Name of other facility (Do you have admitting privileges?
B. APPLICATIONS IN PROCESS
Hospital/Institution
Date application submitted
Page 5 of 11
Name of facility
Previous status (active, provisional, courtesy, temporary, etc.)
Reason for leaving
Appointment date (from– to)
FFILIATIONS
A
PREVIOUS
C.
Name of other facility
NPATIENTCOVERAGE -
ON-CALL PLAN
D. I
For those without admitting privileges, please attach signed letter of agreement from the physician
or group representative that admits and manages the inpatient care for your patients.
For those with admitting privileges, please list the physicians who provide call coverage for you.
Name of admitting physician/practice/clinic/group
Hospital where privileged
Chronologically list all work history activities since completion of professional training (use extra sheets if necessary). This information
must be complete. A curriculum vitae is not sufficient.
Name of current practice/employer
ISTORY
Contact name
Telephone number
From
To
H
WORK
Name of practice/employer
XVII.
Page 6 of 11
(CONTINUED)
Please account for all gaps in time between date of medical / professional school graduation to present not covered elsewhere
within this application. Include dates, activity and names where applicable.
Activity / Name
(Do not abbreviate)
XVIII. PROFESSIONAL AFFILIATIONS
Please List Membership In All Professional Societies
Date Joined
Current Member
Complete Name of Society
REFERENCES
List three professional references, from your specialty area, not including relatives, who have worked with you in the past two years. References must be from individuals who through recent observation, are directly familiar with your work and can attest to your clinical competence in your specialty area. One reference must be from same discipline.
Name of reference
Title and specialty
Cell phone number (optional)
XIX. PEER
Page 7 of 11
Current insurance carrier
Policy number
Origination (retroactive) date
Per claim amount
Aggregate amount
Effective date
LIABILITY
Please list ALL professional liability carriers within the past ten years
Name of carrier
XX.
Mailing Address
XXI. PROFESSIONAL LIABILITY ACTION DETAIL – CONFIDENTIAL
Practitioner name(print or type)
Please list any past or current professional liability claim(s) or lawsuit(s), in which allegations of professional negligence were made against you, whether or not you were individually named in the claim or lawsuit. Please do not include patient names or other HIPAA protected health information (PHI). Photocopy this page as needed and submit a separate page for EACH claim/event. A legible signed practitioner narrative that addresses all of the following details is an acceptable alternative.
Date and clinical details of the incident, with preceding events
Details
Your role and specific responsibility in the incident
Subsequent events, including patient’s clinical outcome
Date suit or claim was filed
Name and Address of Insurance Carrier that handled the claim
Your status in the legal action (primary defendant, co-defendant, other)
Current status of suit or other action
Date of settlement, judgment, or dismissal
If case was settled out-of-court, or with a judgment, settlement amount attributed to you? $
Page 8 of 11 Practitioner Name
Filling out the Idaho Practitioner Application form is a critical step towards successfully applying for credentialing with Blue Cross of Idaho. This comprehensive guide aims to streamline the process. By ensuring every section is filled out accurately and thoroughly, applicants can avoid common pitfalls that delay the credentialing process. Start by gathering required documents and information to have everything at hand. With an average processing time of 60 to 90 days, it's advisable to begin this process well in advance to accommodate any unforeseen delays.
Upon submission, you may inquire about the status of your application via phone or email. Should any information vary significantly from what's provided by external sources during the credentialing process, the Blue Cross of Idaho credentialing staff will reach out for clarification. This step is vital, as accurate information is paramount for a smooth credentialing journey.
What is the purpose of the Idaho Practitioner Application?
The Idaho Practitioner Application is designed for healthcare practitioners seeking to provide their services in affiliation with Blue Cross of Idaho. Its purpose is to standardize the credentialing process, ensuring that all necessary information and documentation are thoroughly and accurately provided by applicants. This form facilitates a comprehensive review of the practitioner's qualifications, education, work history, and professional credentials to maintain high standards of healthcare delivery.
What documents are required to complete the Idaho Practitioner Application?
Completing the Idaho Practitioner Application requires several documents: a fully completed application form, all current and expired state professional licenses, DEA registration information if applicable, detailed education history including dates, board and other certifications, a list of hospital affiliations, a complete work history with explanations for any lapses, a copy of current professional liability insurance showing the required coverage, an Idaho Practitioner Attestation Questions Form, and a Release of Authorization Form. These documents ensure that the credentialing process is thorough and accurate.
How should the application be submitted?
Applications can be submitted via fax at 208-387-6818 or by email to PR2PI@BCIDAHO.COM. This flexibility in submission methods aims to make the process as convenient as possible for applicants. Regardless of the method chosen, it's important to ensure that the application is complete and all supporting documents are included to avoid delays in the credentialing process.
What is the timeframe for the credentialing process?
The credentialing process typically takes between 60 to 90 days from the time Blue Cross of Idaho receives a complete application. Applicants are reminded that all information in the application cannot be more than 180 days old at the time of review to ensure that Blue Cross of Idaho has the most current information. Planning and submitting your application well in advance is advisable to provide ample processing time.
How can applicants inquire about the status of their application?
Applicants have the right to be informed about the status of their application and may contact credentialing staff by telephone or in writing. Credentialing staff are committed to responding to these inquiries within fifteen calendar days, providing updates where available while respecting confidentiality rules around peer-review protected and National Practitioner Data Bank information. This ensures transparency and communication throughout the credentialing process.
Completing the Idaho Practitioner Application form accurately is crucial for practitioners seeking to be credentialed or re-credentialed with Blue Cross of Idaho. While the process itself may seem straightforward, some common mistakes can hinder the application's success. Understanding these mistakes and how to avoid them can significantly streamline the credentialing process.
First and foremost, a frequent mistake is not completing all sections of the application. It's vital to fill out every part or, where applicable, write "Does Not Apply." Simply referring to a Curriculum Vitae (CV) instead of providing detailed information in the form is inadequate and will not be accepted.
Secondly, applicants often forget to list all current and expired state professional licenses, including those outside of Idaho. This oversight can delay the review process, as comprehensive license verification is a crucial step in credentialing.
Another common error involves the DEA Registration section. Some practitioners neglect to provide their DEA registration information, which is necessary for those who prescribe medication. Ensuring this information is complete and current is essential for the application's approval.
In terms of education, work history, and certifications, applicants frequently fail to include start and end dates, which are critical for verifying one's educational background, certification validity, and seamless professional experience. Similarly, failing to detail board certifications or provide copies of professional certifications can stall the process.
Additionally, a significant area often overlooked is the section on hospital affiliations and work history. Listing all current, pending, or previous affiliations, as well as providing a comprehensive work history with explanations for any lapses, is mandatory for a clear understanding of the applicant's clinical background.
Moreover, applicants sometimes omit a copy of their professional liability insurance face sheet, showcasing the required coverage amounts. This documentation is crucial for assessing the risk and professional standing of the practitioner.
Last, but certainly not least, the necessity of completing, signing, dating, and providing an unaltered copy of the Idaho Practitioner Attestation Questions Form along with the Release of Authorization Form cannot be overstated. Any "Yes" responses on the attestation form must be accompanied by a detailed explanation. Failing to fulfill these requirements can result in an incomplete application, delaying or even negating the possibility of credentialing with Blue Cross of Idaho.
To ensure a smooth credentialing process, practitioners are encouraged to meticulously review their applications before submission, correcting any errors and ensuring completeness. Providing ample processing time, as recommended, further facilitates a favorable review outcome.
When completing the Idaho Practitioner Application form, applicants are often required to provide additional documents to ensure a comprehensive credentialing process. Each of these documents plays a vital role in validating the qualifications and professional standing of the applicant. Here’s a look at some of the forms and documents frequently used alongside this application:
Together with the Idaho Practitioner Application form, these documents facilitate a thorough review by credentialing committees, ensuring that only qualified and competent practitioners are given the privilege to practice. It’s imperative for applicants to provide the most current and accurate information to avoid delays or rejections in the credentialing process. Organizing these documents in advance can streamline the application experience, making it more efficient and manageable.
The Idaho Practitioner Application form is similar to other professional credentialing documents in a few ways. It gathers comprehensive information about a practitioner's educational background, work history, certifications, and licensure—details that are crucial for verifying the qualifications and legal standing of healthcare providers. This form plays a significant role in ensuring that practitioners meet the requirements to provide healthcare services within Idaho.
The Medical Staff Credentialing Application used by hospitals and other healthcare institutions is one document that mirrors the Idaho Practitioner Application form in several aspects. Both documents require detailed personal information, including educational history from undergraduate degrees to specialized medical training (e.g., residencies and fellowships), professional licenses (both current and expired), DEA registration, board certifications, and work history, including gaps in employment. These forms also inquire about malpractice insurance coverage, affirming that the practitioner is insured to a minimum required standard. The purpose behind both is to protect patients by ensuring practitioners are competent and qualified to provide healthcare services.
The Universal Provider Datasource (UPD), managed by the Council for Affordable Quality Healthcare (CAQH), also shares similarities with the Idaho Practitioner Application form. The UPD is an online system that collects provider data used in the credentialing process by health plans and other healthcare entities. Like the Idaho form, the UPD asks for detailed education and training information, professional licensure, board certification, work history, and malpractice history. The main difference lies in the UPD's online format, which allows practitioners to enter their information once and authorize its use by multiple organizations. This process contrasts with the paper-based or individual submission format that might be required for the Idaho Practitioner Application.
State Medical License Applications have a lot in common with the Idaho Practitioner Application form as well. While specifics can vary from state to state, these applications typically require detailed information about the applicant's education, training, certification, and professional history—much like the Idaho form. They also include questions about legal or disciplinary history to ensure the applicant is in good standing to practice medicine. The primary purpose of these forms, similar to the Idaho Practitioner Application, is to ensure that only qualified and competent professionals are allowed to provide healthcare services within the state’s jurisdiction.
When completing the Idaho Practitioner Application form, it's important to follow specific guidelines to ensure the process goes smoothly and your application is considered valid. Here are seven things you should and shouldn't do:
Following these guidelines will help ensure that your Idaho Practitioner Application is filled out accurately and completely, thereby facilitating a smoother credentialing process.
One common misconception is that you can substitute a CV for the application form. This is incorrect. The application requires that all sections must be completed in full. Writing "Refer to CV" is not acceptable.
Another misconception is about licensure. It's not just the current but also expired professional licenses that must be listed, including those for Idaho, demonstrating a comprehensive licensure history.
Some might think DEA registration details are only necessary if currently registered. However, the application asks for DEA registration information as applicable, suggesting that it's important to provide this information whether or not it is current.
There's often confusion around the education section, thinking it only pertains to medical school. The form actually requires detailed education information starting from undergraduate education, including start and end dates for all educational phases.
For certifications, it's a misconception that only board certifications need to be listed. In reality, all relevant certifications should be provided, including for nurse practitioners and allied health practitioners, with copies of professional certifications.
Sometimes applicants miss the requirement for a complete work history. It's critical to provide a full work history for the previous five years or since earning your degree, not just recent or relevant positions.
Regarding liability insurance, there's a misunderstanding that you only need to acknowledge having it. The application specifically requires a copy of the current professional liability insurance face sheet showing minimum required coverages.
Lastly, some assume that details about the "Idaho Practitioner Attestation Questions Form" and the "Release of Authorization Form" are not crucial. In fact, these forms need to be completed accurately, signed, dated, and unaltered, with explanations for any "Yes" answers. Compliance with these requirements is essential for the application's validity.
Filling out the Idaho Practitioner Application Form is a critical step for healthcare providers looking to work with Blue Cross of Idaho. Below are four key takeaways to guide you through the process:
By keeping these key points in mind and carefully preparing your Idaho Practitioner Application, you’ll be well on your way to a successful credentialing process with Blue Cross of Idaho.
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