About Our Provider Network
Providers must meet credentialing criteria to become a network provider. The criteria include:
- Signed application and agreement to participate
- Verification of unrestricted state medical license with appropriate licensing agency
- Verification of clinical privileges in good standing on the medical staff at a participating hospital
- Board-certification status with the American Board of Medical Specialties or the American Osteopathic Association
- Verification of education and training
- Review of work history
- Verification of prior sanctioning activities by all regulatory bodies
- Review of any malpractice claims history
- Verification of adequate malpractice insurance
- Facility operating certificate
- Medicare certification
The provider network includes a broad selection of provider types including, but not limited, to primary care, specialists, women's health, behavioral health, vision, dental, hospitals, durable medical equipment suppliers, and pharmacies.
Highmark Blue Shield of Northeastern New York is committed to maintaining an adequate network of primary care, behavioral health, specialty care practitioners, and facility providers to ensure access to care within a reasonable distance in urban, suburban, and rural areas.
Our organization does not use quality measures, member experience measures, cost-related measures, or patient safety measures as selection criteria for allowing providers into the network.
| Item | Description | Source | Frequency of Validation | Limitations (If any) |
|---|---|---|---|---|
| Practitioner Name | Practitioner | Every 3 years. Upon notification from practitioner when changing a name. | None | |
| Gender | Practitioner | Every 3 years. Upon notification from practitioner when updating information. | None | |
| Specialty | The type of care or condition(s) a practitioner specializes in, such as family or cardiac | Practitioner | Every 3 years. Upon notification from practitioner when adding or changing a specialty. | None |
| Medical Group Affiliations | The organizations, companies, or medical groups the practitioner is employed by or associated with. An organization or group may have more than one care site. | Practitioner | Every 3 years. Upon notification from practitioner when adding or changing a medical group affiliation. | None |
| Hospital Affiliations | The hospitals where a practitioner is allowed to admit and care for patients. | Practitioner | Every 3 years. Upon notification from practitioner when adding or changing a hospital affiliation. | None |
| Hospital Name and Location | None | |||
| Hospital Accreditation | An independent accreditation organization has recognized a hospital as meeting pre determined standards for quality of care and service. Two examples are the Joint Commission on Accreditation of Healthcare Organizations and the National Integrated Accreditation for Healthcare Organizations. | Practitioner | Every 3 years. Upon notification from provider when recertifying, adding, or changing an accreditation. | None |
| Board Certification | Board certification involves rigorous testing by a recognized board of the American Board of Medical Specialties and is not required by most states. To verify a provider's board certification and status, visit the American Board of Medical Specialties. | Practitioner | Every 3 years. Upon notification from practitioner when renewing, adding, or changing a board certification. Quarterly review of expired boards. | None |
| Accepting New Patients | Indicates whether a primary care physician or personal physician is accepting new patients. A practitioner may have a full patient roster and cannot accept any new patients at this time. | Practitioner | Every 3 years. Upon notification from provider when accepting new patients. | None |
| Facility New Patient Acceptance | Indicates whether a facility is accepting new patients. | Facility | Upon notification from facility when accepting new patients. | None |
| Languages Spoken | Languages, in addition to the English language, spoken by the practitioner and/or staff. | Practitioner | Every 3 years. Upon notification from provider when adding or changing practice language information. | None |