The Idaho Practitioner Application form is a crucial document for healthcare professionals seeking to establish their credentials in the state of Idaho. This application ensures that all necessary information is collected, including licensing, education, and work history, to facilitate the credentialing process with Blue Cross of Idaho. To begin your journey, fill out the form by clicking the button below.
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
The Idaho Practitioner Application form is a comprehensive document required for healthcare professionals seeking credentialing with Blue Cross of Idaho. It collects essential information about the applicant's education, work history, licenses, and certifications. Completing this application accurately is crucial, as it serves as the foundation for the credentialing process.
When submitting the Idaho Practitioner Application, you must include several important documents. These typically include:
Each document must be current and relevant to your practice. If any document is unavailable, you should indicate the reason why.
To ensure a smooth application process, follow these steps:
Remember, if a section does not apply to you, simply check the box provided at the top of that section.
Submitting an incomplete or outdated application can significantly delay your ability to contract with Blue Cross of Idaho. It is essential that all information is accurate and current. Applications cannot be processed if they lack required information. Therefore, double-check your application before submission to avoid any issues.
The credentialing process typically takes between 60 to 90 days. It is important to allow for this timeframe when submitting your application. Additionally, your application information must be no more than 180 days old at the time of review. Planning ahead will help ensure a timely processing of your application.
If you have questions regarding the status of your application, you have the right to inquire. You can contact the credentialing staff either by telephone or in writing. Expect a response within 15 calendar days. This communication will provide you with an update on your application status, though certain peer-review protected information may not be disclosed.
Here are ten common misconceptions about the Idaho Practitioner Application form:
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