Credentialing/Contracting items 9.2.22

Credentialing/Contracting items

Items Needed for Credentialing/Contracting
Important Notice

Please note that all individual provider information must be completed in your CAQH profile before we can proceed with Contracting/Credential. You are also required to provider us with all of the documentation requested below. If you do not have all the documentation please call us to see how to proceed, otherwise gather everything up before you complete this form. Thank you.
Office Name
Provider Name*

First NameLast Name
What are we contracting you for?*

New Group contract plus one and/or more individual with the groupAdd individual provider to an existing group contract
Items needed for Credentialing an individual provider*

Copy of State Medical LicenseCopy of Diploma(s)Board Certification (if applicable)Copy of DEA (for doctors prescribing meds)Malpractice insurance if different then the group, or group showing individual is coveredCopy of CAQH demographic sheetList of Continuing Education programs completed for last 2 yearsCV/Resume: must contain complete work history also from the time you graduated including reasons for any gap in employment
Items needed for Contracting the group*

Completed the requested Onboarding from sent by Big Sky BillingIRS letter that confirms legal business name and TINCLIA Certificate (for offices doing CLIA waived tests)Copy of Business LicenseMalpractice insurance-(must list all individual providers and clinic locations. Business name listed must match IRS letter)W9- (legal business name must match your IRS letter exactly Line 1 is from your IRS letter, not your personal name)Voided check and Bank Letter-(business name must match your IRS letter exactly)Lease agreement if you have a physical locationType 2 Group NPI number- (must match the IRS letter exactly)
Do you already have your individual and/or group NPI?*

YesNo
Click here to register for NPI
Do you have a CAQH profile?*

YesNo
Insurances are becoming extremely difficult with their credentialing processes These are known issues so your CAQH must be updated with the following information exactly as requested below. Once complete download a copy of the CAQH data profile to send to us.*

Name must match NPI registryMust list all names if you have changed your name for any reasonCurrent home addressPhone numberSocial Security number must be in profileIndividual NPIPlace of Birth must be loaded with City and StateBirth date must be loadedLicense number, license type, and licensing stateLicense issue date and expiration dateEducation- any and all schools must be filled in with end dates and school address. List degree received for each school.List all taxonomy codes that you have listed under your NPI registryBoard Certification information, complete all fields in the sectionPractice location: make sure that you are listing the current practice that we are credentialing you for. All fields must me completed.Tax information under active practice: Name must match what appears on the company's W9 form.Under credentialing information please add Big Sky Billing & Office Management, 625 2nd Ave S, Great Falls, MT 59405. 406-315-7382. Primary Credentialing contact must be marked as "Yes".Malpractice insurance- complete everything to current information- DO NOT CHECK MARK "FTCA"
CAQH IS REQUIRED BY MOST INSURANCES FOR CREDENTIALING

Click here to create CAQH profile
I have everything in order and would like to proceed with uploading my documents. I understand that I must maintain my CAQH profile with attestation that is required every 90 days. Contracting/Credentialing can take more then 90 days so if you do not keep updating your profile you can be denied. If anything changed documentation wise you need to send us a copy at bigskybillingcredentialing@gmail.com. I also understand that I may still be denied contracting/credentialing for any reason that the insurance states and must comply with any update requests with Big Sky Billing within 72 hours.*

Clear
CAQH data profile*

Browse Files

Cancelof
State License*

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Cancelof
Diploma*

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Cancelof
Do you have a Board Certification listed on your CAQH*
Board Certification*

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Cancelof
Malpractice*

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Cancelof
List of Continuing Education

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Cancelof
Do you have a DEA (medical providers only)*

YesNo
DEA license*

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Cancelof
IRS letter

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Cancelof
Business License

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Cancelof
Malpractice Insurance

Browse Files

Cancelof
W9

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Cancelof
Voided Check*

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Cancelof
Bank Letter*

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Cancelof
Are you a mobile clinic?*

YesNo
Lease Agreement*

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Cancelof
Do you have a CLIA license?(waived lab testing)*

YesNo
CLIA license*

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Cancelof
Should be Empty:

Credentialing/Contracting items

Important Notice