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Credentialing Policy for Facility/Organizational Providers

Effective Date: August 1, 2022

General

Credentialing for facility and organizational providers will occur upon initial application with recredentialing required every 3 years after initial approval. Highmark Blue Shield of Northeastern New York will notify you by mail when you are due for recredentialing. Credentialing and recredentialing requirements for facility and organizational providers includes:

  • Completed application
  • Copy of license or business registration
  • For Medicare network:
    • Acceptable proof of participation includes Provider Enrollment, Chain, and Ownership System (PECOS) Web printout that includes revalidation status
    • Medicare Administrative Contractor (MAC) letter confirming revalidation application is approved
    • MAC letter that states initial enrollment is approved (dates on proof must not be greater than 5 years old for all facilities/organizations except for Durable Medical Equipment (DME) prosthetic, orthotic, supplier, or DMEPOS must be revalidated every 3 years)
  • Current proof of liability insurance
  • Clinical Laboratory Improvement Amendments (CLIA) certificate verified as applicable
  • Accreditation or state site survey

Facilities New to Accreditation or Site Survey Requirement

Facilities new to this requirement will have 2 years from the 8/1/2022 implementation date to complete this requirement. New facilities that require accreditation or site survey will require 1 of the following accreditations/surveys listed for each provider type:

  • Ambulatory Infusion Center - Accreditation only
    • Joint Commission (JC)
    • Accreditation Commission for Health Care (ACHC)
  • Birthing Center - Accreditation only
    • Commission for the Accreditation of Birth Centers
  • Residential Treatment Center - Accreditation OR state/Highmark site survey
    • Joint Commission (JC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Council on Accreditation (COA)
    • New York State Office of Mental Health
    • National Association of Private Psychiatric Health Systems
    • Accreditation Commission for Health Care (ACHC)
    • Office of Drug and Alcohol Programs (ODAP)
    • American Association of Partial Hospitalization (AAPH)
  • Laboratory - Accreditation or state/Highmark site survey (if facility has a Certificate of Waiver (CoW), it is exempt from this requirement)
    • College of American Pathologists (CAP)
    • Commission on Office Laboratory Accreditation (COLA)
    • CLIA Certification of Accreditation (COA)
    • CLIA Certificate of Compliance (COC)
  • Skilled Nursing Facilities - Accreditation or state/Highmark site survey
    • Joint Commission
  • Independent Diagnostic Testing Facilities (IDTF) - Accreditation or state site survey
    • Joint Commission (JC)
    • American College of Radiology (ACR)
    • The Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL)
    • The Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL)
    • The Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)                                    
    • American Institute of Ultrasound in Medicine (AIUM)
    • Community Health Accreditation Program (CHAP) for Home/PT/INR based testing only
    • Accreditation Commission for Health Care, Inc. (ACHC)
    • American Academy of Sleep Medicine (AASM)
  • Behavioral Health Facilities/Centers (Professional 1500 Billers) - Mental Health & Substance Abuse - Accreditation or state/Highmark site survey
    • Joint Commission (JC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Council on Accreditation (COA)
    • New York State Office of Mental Health
    • National Association of Private Psychiatric Health Systems (NAPPHS)
    • Accreditation Commission for Health Care (ACHC)
    • Office of Drug and Alcohol Programs (ODAP)
    • American Association of Partial Hospitalization (AAPH)
  • Home Infusion Therapy - Accreditation
    • Joint Commission (JC)
    • Accreditation Commission for Healthcare (ACHC)
    • Community Health Accreditation Program (CHAP)
    • HealthCare Quality Association on Accreditation (HQAA)
    • Utilization Review Accreditation Commission (URAC)
Last updated on 4/14/2022 11:25:46 AM

 

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The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.