Applications and Addenda
Regence BlueShield evaluates all networks on a quarterly basis to ensure that members have access to an adequate number of providers. Based upon that review, an entire network or specific provider types may be 'closed' or 're-opened' to new provider applicants.
In general, all of our networks are 'open' with the exception of:
- Selections (closed in King, Pierce and Snohomish counties)
- Managed Behavioral Health
- Regence BlueShield for PEBB
If you have a question regarding one of our networks or specialty, please call our Professional Relations Department at 1 (800) 562-2156 before requesting an application.
For a copy of the W9 form and instructions please visit
http://www.irs.gov/pub/irs-pdf/fw9.pdf.
Change in Participating Effective Date Policy
Effective April 1, 2008, all physicians and other health care professionals must be credentialed before they can participate in a Regence provider network.
Beginning April 1, 2008, the following policy will apply to all participating providers:
- New provider agreements will have an effective date of the first day of the month in which the provider was credentialed (e.g., if credentialing was approved on June 14, the agreement will be effective on June 1).
- If Regence does not receive a signed agreement in the same month as credentialing is completed, the agreement effective date will be the first of the month in which credentialing is approved or the signed agreement is received, whichever is later.
- A new provider joining a group or clinic agreement will have an effective date of the first day of the month in which he or she was credentialed (e.g., if credentialing was approved on June 14, the effective date of participation will be June 1).
- If a provider already participating with Regence adds an additional network, the effective date of the new network will be the first day of the month the signed agreement is received.
- Regence will no longer establish retroactive agreement effective dates.
- Claims submitted to Regence for dates of service prior to the provider’s effective date will be processed as out-of-network.
If you have any questions regarding this policy, please contact your provider consultant.
| Contracting & Credentialing
Forms |
| Form |
Description |
Instructions |
Practitioner
Credentialing Criteria for Participation and Termination (PDF)
(effective 11/1/ 2007)
Organizational
Provider Credentialing Criteria for Participation and Termination (PDF)
(effective 11/1/ 2007)
|
This document explains our organizational requirements for
requesting participation and continued participation with Regence BlueShield.
All practitioners and organizational providers must complete an application
for participation so we may perform a comprehensive review of the provider's
credentials. Once the application is completed, we will begin a review of
the practitioners or organizational credentials using a variety of national
and state data sources. |
|
| Washington
Practitioner Application (2007 version) (PDF) |
This form must be completed to begin the process of credentialing.
|
| |
Complete the form in its entirety using black or blue ink. |
| |
If a particular question does not pertain to you or your practice,
please check the box at the tops of that section. |
| |
Keep an unsigned and undated copy in your files for any future requests,
if necessary. |
| |
Attach copies of requested documents. |
|
If changes are made to the completed application, strike out the
information and write in the modification, initial and date. |
|
Document any ‘YES’ responses on the Attestation Question
page. |
|
Expect addendum’s from the requesting organizations for information
not included on this form. |
|
Send completed form to P.O. Box 21267, Mail Stop S916, Seattle WA
98111-3267 |
|
Universal
Facility Application (PDF) |
This form must be completed to begin the process of credentialing. |
| |
Complete the form in its entirety using black or blue ink. |
| |
Indicate if initial credentialing or recredentialing |
| |
Attach copies of requested documents |
|
If a question does not apply to your facility, answer with ‘Not-Applicable’
or ‘N/A’. |
|
If additional space is necessary to provide answers, attach additional
sheet(s) of paper. |
|
Keep an unsigned and undated copy in your files for any future request,
if necessary. |
|
Application must be signed and dated where indicated. |
| |
Send completed and signed form to P.O. Box 21267, Mail Stop S916,
Seattle WA 98111-3267. |
|
About Applications and Addenda: Follow the instructions
included on each form. Mail the completed documents
back to Regence BlueShield at the following address:
Regence BlueShield
1800 Ninth Avenue
PO Box 21267
Mailstop S916
Seattle, WA 98111-3267
Phone: 1 (800) 562-2156
Note: To print a PDF document, you need Adobe® Acrobat® Reader. Download it now for free.
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