How to Become a Blue Shield of California Provider

Guide to joining Blue Shield of California

Agreement

1. Agreement - Download the Blue Shield of California Agreement - Click Here
2. Website - Although not necessary, here is the BS California Provider Website
3. Phone Contact - If you need to, the contact number for help with the application is (800) 258-3091
4. Pages To Complete - page 2, page 3, page 24, page 25, page 26, page 27 - Note: the other pages are the details of the contract you are signing. This is a legally binding contract, so I suggest reading it to understand what you are agreeing to. If you are unsure, seek legal council or call Blue Shield.
5. Send it in - Send in all documentation by one of the following methods:

1. Confirmation - Participating Providers will be assigned an effective date based upon completion of Blue Shield Credentialing if applicable, and the receipt and completion of all required documentation. A copy of the executed Agreement (if submitted), including the assigned effective date, will be returned to you when processing is completed.

Credentialing

1. Call Credentialing and request a "credentialing application" - (888) 398-2250
2. Fill out the credentialing application.
3. Send in your application

AGREEMENT—Items you must send to Blue Shield of California

1. Provider Identification Number Application Form - Completed PIN Application signed by the provider of service, owner/director, or corporate officer.
2. Include a copy of current license issued by the California State Board of Examiners or National Board Certification for professionals not licensed by the State of California.
3. Employer Identification Number - If earnings are to be reported under an Employer Identification Number (EIN), include a copy of pre-printed IRS documentation showing EIN/Name combination recognized by the IRS. (SS-4 form, 147-C form, or copy of the Federal Tax Deposit Coupon, are examples of acceptable pre-printed documents.)
4. National Provider Identifier- If the individual provider or entity has a NPI number, include a copy of the E-mail notification from the Enumerator or NPPES screen print or CMS / Enumerator notification letter.
5. Group Roster- If a group/business, include a group roster listing the individual provider name(s), license number(s), and NPI number(s).
6. Articles of Incorporation - If incorporated, include a copy of the current Articles of Incorporation from the Secretary of State.
7. Fictitious Name Statement or Permit- If using a fictitious name, provide a copy of the current Fictitious Business Name Statement from the provider’s county , or, Optometry businesses using a fictitious name include a copy of the Fictitious Name Permit from the Optometry Board of California.
8. Allied and Ancillary Provider Agreement - Completed Allied and Ancillary Provider Agreement signed by the owner, director, or corporate officer. Some provider types must be credentialed by Blue Shield prior to execution of the Agreement. If entity is a group/business; provide group/business name on page 1 and Exhibit A. Please return ALL pages of the agreement for processing. Altered Agreements will be voided and returned.

CREDENTIALING—Items you must send to Blue Shield of California

• Credentialing application - Signed and dated.
• Information about any malpractice actions that may have been taken against you, including settlement amounts and/or explanation of any dismissed or pending claims with pertinent dates included (see application page 4 of 7).
• Hospital privilege including any additional information as applicable (see application page 5 of 7).
• Curriculum vitae - Please include an explanation of any work history gaps greater than six months
• Current Malpractice Liability Insurance Certificate - Current Blue Shield of California requirements are $1 million per occurrence and $3 million aggregate for all contracted practitioners except Allied Health Providers who require $1/$1 million.
• Copy of your Drug Enforcement Administration (DEA) certification, if applicable.
• Copy of your current license.

What to expect when you are done