BCBSM PHASE 2: MARCH 1st NON-COMPLIANCE PENALTY 20%
The BCBSM Credentialing Roadmap
In order to meet the BCBSM deadline of March 1, 2027, you will need to start the credentialing process for your Nurse Practitioner's early. Why? The deadline will create a backlog and it normally takes from 30 to 120 days. BCBSM applications are faxed and they communicate issues and approval via mail. Only under certain conditions will they opt to phone or send a fax. They are not digital in their processes. Use our blueprint template to simplify the process and avoid unnecessary delays. But if you decide that you are not interested in doing this in-house, learn more about how we are helping Michigan practices navigate this change with a special fast-track package.
Act Now To Avoid Revenue Risks
Phase 1: Effective September 1, 2026. Billers must append the "SA" modifier code to any claim where a Nurse Practitioner is the rendering provider under a Doctor's NPI. The SA modifier instantly disqualifies claims from Value-Based Reimbursement and Physician Group Incentive Program incentives.
Phase 2: Effective March 1, 2027, the transition period ends. BCBSM requires all enrollment-eligible clinicians to bill directly under their unique individual NPIs. The penalty for staying Incident-To billing is a 20% reduction of the standard professional fee schedule.
The Solution: to avoid the 20% payment penalty and retain eligibility for VBR and PGIP incentive bonuses, fully credential and enroll the Nurse Practitioner individually with BCBSM. The credentialing process can take 30 to 120 days to process. Your project timeline needs to be account for gathering source documents, winter holidays. and handling issues that may come up.
Other Consequences: This requirement varies by payer. However, Medicare prohibits it for new patients and new conditions. Recently, peers are reporting that some practice owner's have been blindsided by Medicare audits. Noncompliance results in recoupment of overpayments and civil monetary penalties.
Don't worry, we can help!
Model Our Plan
Use buttons to navigate to each section to build your own plan
4 Main Areas To Manage
NPPES CMS Registry
Validate and certify the Practitioner and Group NPI data in the NPPES Registry. Why? Federal No Surprise Act places burden on insurance to assure they are not using stale or invalid data.
Certify NPI Data
Medicare PECOS
Link/validate the Nurse Practitioner's NPI inside PECOS, if applicable. Why? BCBSM operates massive government-backed networks, Blue Cross Medicare Advantage
Link NPI to PECOS
CAQH Proview
Make sure CAQH has accurate provider data and documents attested prior to and after submitting BCBSM enrollment app. Ensure the CAQH internal review occurs pre-submission.
Complete CAQH
BCBSM Enrollment
Submit the NP's BCBSM Practitioner Application. Note the 14-day requirement. BCBSM mandates CAQH profile must be re-attested within 14 days of submitting the application form and accessible to them.
Enroll in BCBSM
THE CREDENTIALING PROJECT:
Do not underestimate the effort or time it takes to complete the process.
Most people tend to underestimate the time it takes to gather all the source documents and complete the entire process. It's essentially a project and the more providers you are credentialing, the more complex it becomes. There is a certain amount of back and forth between the credentialing specialist, the provider, and the practice owner that simply cannot be avoided. Coordinating those touchpoints and responses can add significant delays to the process.
Schedule tasks and reminders
This is a time sensitive project. Missed deadlines can negatively impact your revenue cycles. Once enrolled in BCBSM, you must attest your CAQH ever 90 days which is more frequent than the 120 day standard. Why? Blue Cross Blue Shield of Michigan (BCBSM) requires directory data to be attested every 90 days to comply with federal law under the Consolidated Appropriations Act
Define Role & Responsibilities
Set clear expectations about requirements and timely responses required from the Provider, Practice Owner, and Credentialing Specialists.
External Bottlenecks
Closely monitor progress from external sources that provide source documents. Escalate as needed.
Handle Issues ASAP
If there are issues with documentation or BCBSM needs additional data, handle these matters immediately.
Your BCBSM Credentialing Roadmap
Prepare
Create list of documents and data needed for CAQH, NPPES, Availity, IRS, BCBSM (PPO/HMO), etc
List all accounts needed across source systems and other sites.
Sset up all required access ids/passwords and securely store them
Ensure NPPES/PECOS is updated completely
Request/gather source documents. Factor in request/fulfillment times
Receipt & Internal Audit
Check data received for completeness and complete CAQH profile
Check for discrepancies between sources and CAQH, e.g. names, business name/address, DBA, taxonomies, gaps in employment history
Be meticulous. Address any gaps and fix all discrepancies
Ensure you have the official IRS letter CP-575 (or Letter 147C), and DBA Certificate if applicable
Payer Requirements
Ensure CAQH has all documents uploaded and attested.
Complete BCBSM provider enrollment app. Ensure signatures 7 dates are compliant
Fax app, IRS letter, DBA cert, signature pages. Confirm successful transmission. Clock starts for 14 day rule.
Keep copy of fax status page showing success, send date, the number of pages sent, and the target phone number
After App Submitted
Attest CAQH Profile as soon as possible after submitting application
Confirm BCBSM is authorized to view Profile
BCBSM has no online status tracking system and it communicates by mail, phone, or fax :-(
BCBSM instructs you to wait 30 days before calling for a status
Critical Checks
Note dedicated BCBSM Enrollment number, and their ID verification process
Proactively monitor the status by calling and address all issues
BCBSM will mail your approval letter with the effective date.
You cannot bill for PPO or HMO services prior to their effective dates
BCBSM Final Steps
BCBSM will electronically transmit the official BCN HMO contract after the PPO is approved. BCN contract will be sent to the authorized signer on file using DocuSign
Once application is approved: Use Availity Essentials to submit EFT and ERA to direct payments to clinic owner's bank account
You will receive separate approval/effective date letter from HMO side
In-House Vs. Expert Support
Once you assess the scope of this project, then you can decide if you will keep this work internal or use a service like ours. Many practices that don't have dedicated credentialing staff decide it's better to work with us and remove unnecessary friction and risk of delays. If you will be doing this project in-house, allow extra time. But if you are interested in having expert support, we have created a special offer for Michigan Clinics and Providers. See details below.
BCBSM Fast-Track: A Special Offer
To support providers in their effort to prepare for this upcoming change, we have created a special offer just for Michigan Providers. This package will address NPPES profile certification, full CAQH alignment, BCBSM Practitioner form submission with primary source document packaging, and tracking until the BCN DocuSign is issued.
The First Mid-Level Staff
$199 flat fee
Add up to two additional staff
$150/team member
Or add 3 or more staff
$125/team member
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Limited Reservations
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