Contracting/Credentialing
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| Q. |
What is required for me to join BCBSTX’ managed care networks? |
| A. |
First, you must obtain a National Provider Identifier (NPI) number from the National Plan and Provider Enumeration System (NPPES). Then, you must obtain from Blue Cross and Blue Shield of Texas (BCBSTX) a provider record by calling Provider Administration at (972) 996-9610. View more information regarding your provider record with BCBSTX, completion of a credentialing application as well as contracts for the networks in which you wish to participate.
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| Q. |
Is applying for a provider record with BCBSTX the same as applying for participation in your PPO/HMO networks? |
| A. |
No. You cannot apply to the PPO/HMO networks until you are issued a provider record with BCBSTX. Obtaining a provider record only loads you in the system for claims processing purposes. Participation in the PPO/POS and HMO networks requires contracting and credentialing.
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| Q. |
How can I request an application for network participation? |
| A. |
Request an application online or contact your local Professional Provider Network office.
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| Q. |
On the contracts/agreements with IPAs, is the physician’s or other professional provider’s effective date based on delegation? |
| A. |
No. The physician’s or other professional provider’s effective date is based on BCBSTX’ assigned effective date.
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| Q. |
What is the length of time that a physician or other professional provider can be out of the network before they have to be fully credentialed again? |
| A. |
BCBSTX does not allow more than a 30 day gap in credentialing. If it has been over 30 days, then the physician or other professional provider will need to be fully credentialed again.
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| Q. |
Are the physician and other professional provider fee schedules/reimbursement percentages available on the BCBSTX Web site? |
| A. |
To access BCBSTX general reimbursement information policies, request forms for allowable fees and fee schedule information, visit the General Reimbursement Information section of the site. To request a sample of maximum allowable fees or if you have any questions, contact your local Professional Provider Network office.
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| Q. |
How do I request a fee schedule? |
| A. |
Complete the fee schedule request form, or send the request in writing (by mail or fax) to your local Professional Provider Network office. Be sure to include your NPI number and the schedules you are requesting (ParPlan, BlueCHoice and/or HMO Blue Texas).
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| Q. |
Can you obtain the full fee schedule? |
| A. |
Generally we provide an “ample sample” which covers the more frequently billed CPT codes. General Reimbursement Information is also available on the Web site. If you have specific CPT codes you would like information and cannot locate on the Web site, please include these in your request.
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| Q. |
How long does it take to get information regarding fee schedule requests? |
| A. |
Normally, most requests are processed within seven to 10 business days. Full fee schedule requests take longer.
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| Q. |
Medicare changed our Medicare provider number. Do we need to notify BCBSTX? |
| A. |
No.
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| Q. |
We have a financial agreement with our patients to be responsible for whatever insurance does not cover. Are we able to demand payment from the member? |
| A. |
The Provider Claim Summary indicates the patient's share. You cannot bill the patient in excess of the coinsurance, deductible and non-covered charges.
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| Q. |
What is ParPlan? |
| A. |
ParPlan is a BCBSTX payment agreement under which health care professionals agree to:
- File all claims for BCBSTX patients through BCBSTX
- Accept the BCBSTX allowable amount
- Only bill BCBS subscribers for deductibles, cost-share (coinsurance) and medically necessary services which are limited or not covered either at the time of service or after BCBSTX has reimbursed you
- Not bill BCBSTX for experimental, investigative or otherwise unproven or excluded services
- Not bill either BCBSTX or the subscribers for covered services which are not medically necessary
The ParPlan obligation of the physician or other professional provider applies to subscribers of any BCBS plan.
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