Credentialing Policy for Professional Providers

Effective Date: August 1, 2022

License

All providers must have a current active license to practice in the state(s) where they provide care for the Highmark Blue Cross Blue Shield of Western New York’s members, with verification directly from the state licensing agency. 

Highmark will verify the licenses listed below for the following specialties:

• Genetic Counselors
  • Genetic counselors in network prior to 8/1/2022 will be grandfathered
  • Genetic counselors in network are not licensed but will be required to maintain current certification through the American Board of Medical Genetics and Genomics (ABMGG) or the American Board of Genetic Counseling (ABGC)
  • After 8/1/2022, we will no longer enroll new genetic counselors into our network
• Certified Registered Nurse Practitioners (CRNP), Clinical Nurse Specialists (CNS)
  • CRNPs and CNSs will need to have both Registered Nurse and Advanced Practice license verified
• Certified Registered Nurse Anesthetist (CRNA)
  • CRNAs will need to have Registered Nurse license verified as well as certification by a national certifying board
• Certified Midwife
  • Certified Midwifes will require licensure as a Midwife
  • Registered nurse license will be verified if applicable
• Behavioral Health
  • Licensed Professional Counselors, Licensed Mental Health Counselors, Marriage and Family Therapists, Licensed Behavior Analysts, and Massage Therapists are not eligible for the Medicare Advantage network because they are not Medicare eligible providers
  • The Behavioral Health practitioner specialties listed above ARE eligible to apply for participation in commercial plan networks

IMPORTANT: Highmark’s verification process does not require any additional information from you during the initial credentialing or recredentialing process. If we are not able to verify your license, we will contact you for more information at that time.

Drug Enforcement Administration (DEA)

Providers who are eligible to prescribe narcotics must have a DEA certificate or a plan of action with another in-network provider that will prescribe narcotics on their behalf.

Board Certification

New York providers in network prior to 8/1/2022 will be grandfathered for board certification and processed as routine. Initial providers beginning 8/1/2022, will need to be board certified, or meet one of the following exceptions:

• Completed training prior to December 31, 1987
• Board Eligibility Period: Providers have 6 years post-residency or fellowship completion to obtain board certification
• Rural Exception: Zip code of practice location has been determined to be a rural location

Acceptable board certifying agencies:

• Physicians: Member boards of the American Board of Medical Specialties (ABMS) and American Osteopathic Association (AOA)
• Podiatrists: American Board of Podiatric Medicine (ABPM) (formerly the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM)) or the American Board of Foot and Ankle Surgery (ABFAS) (formerly the American Board of Podiatric Surgery (ABPS)); for Podiatrists who have completed residency training but who are no longer eligible for certification by the boards listed above, board certification by the American Board of Multiple Specialties in Podiatry will be considered as an exception
• Dental Physician Specialists: American Board of Oral and Maxillofacial Pathology, American Board Oral and Maxillofacial Surgery or the American Academy of Oral and Maxillofacial Radiology.

Malpractice Insurance Coverage

• Physicians, Certified Registered Nurse Practitioners, Clinical Nurse Specialists, Certified Midwives, Podiatrists, Dental Specialists and General Dentists must have no less than $1,000,000 per claim and $3,000,000 aggregate per year coverage
• Chiropractors, Behavioral Health Specialists and Allied Health Providers must have no less than $500,000 per claim and $1,500,000 aggregate per year coverage

24/7 Coverage

Several specialties have been added to the 24/7 coverage requirement. Unless you are one of the specialties below, you must provide 24/7 coverage:

• Audiologists
• Dieticians/Nutritionists
• Certified Diabetic Educators (CDE)
• Occupational and Physical Therapists
• Speech/Language Pathologists
• Dermatopathologists
• Non-Hospital-based Pathologists and Oral and Maxillofacial Pathologists
• Read-only Practitioners and Psychologists that perform neuropsychological testing or psychological evaluations only

NOTE: CRNA 24/7 availability must be with performing surgeon(s)

Practitioner must be able to provide coverage for patients and provide them with triage and appropriate treatment or referrals for treatment 24/7.

For behavioral health providers, a referral to a crisis line is not acceptable coverage unless there is an arrangement made between the provider and the crisis line whereby the provider (or his/her designee) can be contacted directly, if needed.

Hospital Privileges

Primary Care Practitioners (Physicians, CRNPs):

• Provider must have admitting privileges in good standing at a Highmark network and/or BCBSA participating hospital (as appropriate) or have alternate arrangements for admitting enrollees; the hospital must accept all lines of business that the provider is applying/credentialed for
• Alternative arrangements: provider will have coverage for hospital admissions and hospital care of members with a network(s) participating practitioner or group that
• Is in the same networks, AND
• Has admitting privileges at a network participating facility and/or a BCBSA participating hospital AND
• Is of the same or similar specialty type

Physician Specialists

• Applicable physicians must have admitting or clinical privileges in good standing at a Highmark network and/or BCBSA participating hospital (as appropriate); the hospital must accept all lines of business the provider is applying/credentialed for
• Alternative arrangements: provider is required to have coverage for hospital care of members with a network participating practitioner or group who
• Is in the same networks
• Has admitting or clinical privileges at a network participating facility and/or BCBSA participating hospital AND
• Is of the same specialty type