The Idaho Practitioner Application form serves as a crucial step for healthcare professionals aiming to validate their credentials and align with the requirements set by Blue Cross of Idaho. It encompasses a comprehensive checklist that includes sections on completed applications, licensure details, DEA registration, educational background, certifications, hospital affiliations, professional work history, and liability insurance, ensuring each candidate meets the rigorous standards for healthcare practice within the state. Prospective applicants are guided to meticulously fill out the form, ensuring accuracy and completeness to prevent delays in their credentialing process. Click the button below to embark on the initial step towards credentialing with Blue Cross of Idaho, bringing professional healthcare services closer to the community.
The Idaho Practitioner Application, revised in September 2014, serves as a comprehensive tool for practitioners seeking credentialing with Blue Cross of Idaho. This thorough application process is designed to ensure that all potential healthcare providers meet the stringent requirements set forth by Blue Cross, ensuring the delivery of high-quality healthcare services. It requires detailed information on various aspects, including but not exhaustive to personal and practice information, professional licensure, education, certification, and hospital affiliations, along with a documented work history over the previous five years. The application mandates the listing of current and expired state professional licenses, DEA registration details, educational credentials with start and end dates, board and other certifications along with copies of professional certifications for nurse practitioners and allied health practitioners, and a comprehensive work history. Additionally, applicants must provide documentation of liability insurance with specific coverage amounts and answer attestation questions truthfully, with the provision for explaining any affirmative answers. It is vital for applicants to ensure the application is complete, accurate, and submitted within 180 days of review to facilitate a smooth credentialing process, which typically spans 60 to 90 days. Blue Cross of Idaho allows for submissions via fax or email and emphasizes the importance of accuracy and completeness, as failing to provide correct information can significantly delay the credentialing process. This application not only streamlines the process of joining Blue Cross of Idaho's network but also underscores the commitment to maintaining high standards in the healthcare industry by gathering comprehensive background information on each practitioner.
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
Preparing an Idaho Practitioner Application requires attention to detail and completeness to expedite the credentialing process with Blue Cross of Idaho. It's crucial to understand that the application should be filled out comprehensively, and any sections that do not apply must be clearly marked as such. Missteps or missing information can lead to delays. The process also entails submitting several supporting documents and ensuring the information is no older than 180 days at the time of review. With careful adherence to the following steps, professionals can successfully navigate the form submission, moving toward credentialing without unnecessary hindrance.
Upon completion, the application, alongside all required documents, should be faxed to 208-387-6818 or emailed to PR2PI@BCIDAHO.COM. Ensure your application is submitted within the timeframe that keeps your information within the 180-day freshness requirement. Expect the review process to take between 60 and 90 days. During this period, you may inquire about the status of your application if needed, though the review outcome will ultimately be communicated in writing. Proper execution of these steps ensures that your application proceeds smoothly, avoiding procedural delays that could impact your ability to contract with Blue Cross of Idaho.
What documents do I need to submit with the Idaho Practitioner Application form?
When submitting the Idaho Practitioner Application, you must include the application itself, ensuring all sections are fully completed. Also, provide current and any expired state professional licenses, DEA registration information, educational history, board certifications, a copy of your current professional liability insurance face sheet showing a minimum coverage of $1,000,000/$3,000,000, details of hospital affiliations, a comprehensive work history for the past five years or since obtaining your degree, and complete the Idaho Practitioner Attestation Questions Form with explanations for any "Yes" answers. Additionally, submit a Release of Authorization Form, all duly signed and dated. Note, information in your application should not be older than 180 days at the time of review by Blue Cross of Idaho.
How should I complete the Idaho Practitioner Application?
The application should be completed in black or blue ink and signed and dated on pages 9,
Can I reference my Curriculum Vitae (CV) instead of filling out certain sections of the application?
No, referencing your Curriculum Vitae (CV) as a substitute for completing the application is not acceptable. You must fill out all sections of the application thoroughly. If a particular section does not apply to your situation, you should indicate that by checking the "Does Not Apply" box provided in that section.
What happens if there is a mistake in the application or if my situation changes after I submit the application?
If you need to correct information in your application after it has been completed, you should strike through the incorrect information, write the modification near it, and then initial and date the change. It's crucial to keep an unsigned and undated copy of the application for future reference or if any updates are required.
What is the process for inquiring about the status of my application?
Applicants have the right to be informed about the status of their credentialing application. You can contact the credentialing staff via telephone or in writing to inquire about your application's status. The staff will respond within fifteen calendar days, either through the same communication method used for the inquiry or in writing, to provide an update.
How long does it take for the credentialing process to be completed?
On average, the credentialing process with Blue Cross of Idaho takes 60 to 90 days. It's important to provide ample processing time when submitting your application. Keep in mind, incomplete or outdated applications cannot be accepted or processed, and incorrect information will delay your ability to contract with Blue Cross of Idaho.
Filling out the Idaho Practitioner Application form is a crucial step for healthcare professionals in Idaho seeking to be credentialized or to renew their credentials. However, applicants often make errors that can delay or impact their ability to contract with Blue Cross of Idaho. Beneath, the nine common mistakes are outlined to help applicants avoid these pitfalls.
Not completing all sections: A frequent oversight is not fully filling out the application or failing to indicate “Does Not Apply” where appropriate. Skipping sections or referencing external documents like a CV instead of providing information directly in the application can result in processing delays.
Omission of license details: Applicants sometimes neglect to list all their current and expired state professional licenses, including those for Idaho. This comprehensive history is vital for the credentialing process.
Incomplete DEA registration information: For those applicable, failing to provide DEA registration details can be a stumbling block. This information is crucial for credentialing and must be accurately furnished.
Education timeline gaps: Not specifying the start and end dates for all educational programs attended is another common mistake. Accurate timelines help credentialing bodies understand your educational background.
Insufficient certification documentation: Some applicants forget to provide board certification information or copies of professional certifications. This documentation is essential to verify qualifications.
Overlooking hospital affiliations: A detailed listing of current primary admitting facility and other affiliations is required. Incomplete information on hospital affiliations can signal a lack of requisite experience or eligibility.
Vague work history: Applicants often provide incomplete work histories or do not adequately explain employment gaps for the previous five years or since earning their degree. A full work history offers a comprehensive view of an applicant's professional experience.
Neglecting liability insurance details: A common mistake is failing to include a copy of the current professional liability insurance face sheet, which must show a minimum of $1,000,000/$3,000,000 in coverage.
Incorrect application attestation: Not providing a completed, signed, dated, and unaltered Idaho Practitioner Attestation Questions Form, along with a written explanation for any “Yes” answers, can significantly delay the process. Applicants must accurately disclose any pertinent issues that could affect their credentialing.
To mitigate these errors, applicants are encouraged to thoroughly review their application for completeness and accuracy before submission. Ensuring that all sections are fully completed and that all required documentation is attached can streamline the credentialing process. Moreover, it is advisable to keep a saved copy of the application for future reference or updates, adhering to the instructions that any necessary changes to the completed application should be crossed out, modified, initialed, and dated.
In conclusion, avoiding these common mistakes not only facilitates a smoother credentialing process but also highlights the practitioner's attention to detail and professionalism. Given the importance of this application in establishing one’s eligibility to provide healthcare services within the network, taking the time to meticulously review and complete the application is well worth the effort.
Completing the Idaho Practitioner Application form is an important step for healthcare providers wishing to practice in Idaho. To ensure a comprehensive and streamlined application process, several other documents are typically required along with the Idaho Practitioner Application form. Understanding each of these documents will help applicants prepare their application packets more effectively.
Along with the Idaho Practitioner Application form, these documents form a crucial part of the credentialing process for healthcare providers. Together, they give a comprehensive view of the applicant’s qualifications, legal compliance, and readiness to provide healthcare services. It is important for applicants to ensure that each document is current, accurate, and complete to avoid delays in the credentialing process. Being thorough and organized can significantly enhance the application experience.
The Idaho Practitioner Application form is similar to other healthcare credentialing documents in various respects, primarily regarding the critical information they collect from applicants. The purpose of these documents is to ensure practitioners meet the set criteria for professional and ethical practice within healthcare institutions.
The Federation Credentials Verification Service (FCVS) application shares notable similarities with the Idaho Practitioner Application. Both documents require detailed information on the practitioner’s educational background, work history, and professional licensure. The FCVS specifically focuses on centralizing the verification process for physicians and other health professionals moving between states or applying for hospital privileges. This shared focus on thorough vetting ensures that only qualified professionals are admitted to practice, which directly correlates with the objectives of the Idaho Practitioner Application in its requirement for a comprehensive history of education, licenses, and certifications.
The National Practitioner Data Bank (NPDB) Self-Query is another document that bears resemblance to the Idaho Practitioner Application, particularly in its purpose of maintaining the integrity of the healthcare profession. While the NPDB self-query provides a mechanism for practitioners to review their own records for accuracy, the Idaho application requires practitioners to disclose similar information upfront, including any lapses in work history and the status of professional licenses. Both documents are instrumental in preempting any discrepancies that may affect a practitioner’s eligibility to practice, fostering transparency, and trust in healthcare engagements.
The Curriculum Vitae (CV), often used by healthcare professionals when applying for positions, parallels the Idaho Practitioner Application in its requirement for detailed professional and educational history. The Idaho form specifies that referencing a CV is not an acceptable substitute for completing the application. This stipulation underscores the application’s requirement for standardized information submission, facilitating a direct comparison among applicants. Both the CV and the Idaho form serve to provide a comprehensive overview of an applicant's qualifications, albeit in different contexts.
In summary, while each document—the FCVS application, the NPDB Self-Query, and the Curriculum Vitae—serves distinct functions within healthcare credentialing and employment, they align with the Idaho Practitioner Application in their collective aim to ensure that the qualifications and history of healthcare professionals are thoroughly vetted and documented. This alignment underscores the healthcare industry's commitment to maintaining a high standard of practice and protecting patient safety.
When completing the Idaho Practitioner Application form, certain practices should be followed to ensure that the process is completed smoothly and effectively. Here are the things you should and shouldn't do:
What You Should Do:
What You Shouldn’t Do:
When it comes to filling out the Idaho Practitioner Application form, there are several misconceptions that can trip up applicants. Let's clear up eight common ones:
Understanding these common misconceptions can make the application process smoother and help avoid unnecessary delays. Ensuring every detail is accurate and adhering to the instructions provided in the application will contribute to a successful submission.
When filling out and using the Idaho Practitioner Application form, it's essential to keep the following key takeaways in mind:
It's crucial to maintain an up-to-date copy of the application, unsigned and undated, for future submissions. When submitting the application, ensure all provided information is current, complete, and accurate. Ample time should be allowed for processing, considering that the credentialing process can take 60 to 90 days, and application information should not be more than 180 days old at the time of review. Incomplete or outdated applications will not be accepted, which may delay the credentialing process and affect the possibility of contracting with Blue Cross of Idaho.
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