Independence Ancillary Credentialing 1.6 20171030

In order to qualify as a participating ancillary Provider for Independence Blue Cross and its affiliates ("Independence"), a Provider must meet requirements which include, but are not limited to the following:
  1. A current unrestricted license as required by state or federal regulations. A certificate of registration is acceptable for durable medical equipment providers in Pennsylvania.
  2. Accreditation by an Independence recognized accrediting body, if required for provider specialty type.
  3. Eligibility in good standing to participate in Medicare, Medicaid and other governmental health programs. In order to participate in any of Independence's Medicare Advantage benefits programs, Provider must be certified by or participate with Medicare.
  4. Maintenance of professional and property liability at a level that complies with state or federal regulatory requirements or, if not regulated for provider type, meets community standards.
  5. Maintenance of an active, documented quality management program including, at a minimum, the following items with copies of such documentation made available to Independence upon request.
    • Structured documents of Providers quality control and improvement program, including their written plan
    • Provision for 24 hours/day, 7 days/week emergency coverage
    • Process to assure professional staff credentialing/recredentialing, including verifying the credentials of subcontracted individuals
    • Structured patient/family satisfaction survey process
  6. Providers must agree that any and all covered services provided to members of Independence will be provided directly by Provider or a subcontractor as specifically approved by Independence. Provider must disclose the name of all organizations with which it subcontracts for covered services, and must assure that subcontracted providers meet Independence's standards as listed herein. Provider shall ensure that all approved subcontractors are not excluded from participation in Medicare, Medicaid and/or other federal health care programs. Provider understands that the list of excluded individuals and entities are available on the website of the Office of Inspector General.
  7. Provider must have a valid national provider identifier (NPI) and taxonomy number.
Please be sure that you have included the following items with your submission in order to expedite the review process. Independence conducts a full assessment of all Provider applicants. We will not process incomplete applications or maintain incomplete assessment files due to regulatory concerns.
  1. Copy of National Provider Identifier and taxonomy number
  2. Copy of incorporation papers and, as applicable, fictitious name filing
  3. Copy of state license, certification, or registration
  4. Copy of final accreditation letter (if applicable)
  5. Copy of CMS or state survey (if applicable)
  6. Medicare and Medicaid information with documentation from CMS
  7. Copy of face sheets for current liability insurance
  8. Description of process to ensure current licensure for professional staff
  9. Description of procedures to assess patient/client satisfaction and summary of last assessment
  10. A completed Personnel Roster form
  11. Copy of W-9 for tax identification number (IRS requirement)

In accordance with our accreditation and/or regulatory requirements, Independence will complete reassessment every three years to ensure Provider's continued compliance.

Independence reserves the right to limit Provider participation with Independence based on its business or network needs.


Independence Ancillary Credentialing 1.6 20171030