(You will need Adobe Acrobat Reader to view or print items on this page.)

Thank you for your interest in becoming a part of the professional mental health network of Companion Benefit Alternatives, Inc. (CBA). This network encompasses plans for Preferred Blue^®, BlueChoice^® HealthPlan, the Federal Employees Program (FEP) and Planned Administrators, Inc. (PAI.)

On behalf of BlueCross, CBA administers mental health and substance abuse benefits and PAI offers third party administration services. CBA and PAI are separate companies.

Below is a checklist of the information needed for credentialing. If you are in a group practice, please ensure that all group members are or will be credentialed so that you will be recognized as participating in the CBA network.

1. Read, complete, sign and return the application.
2. Read, sign and return the CBA Professional Agreement (Please contact CBA at 1-800-868-1032, ext. 25744 to get this document.)
3. Sign and return each HMO Hold Harmless Agreement.
4. Enclose a copy of the State License(s).
5. Enclose a copy of the DEA License (if applicable).
6. Enclose a copy of the NPI assignment letter.
7. Enclose proof of current malpractice coverage.
   

• All non-MDs should have coverage as follows: $1,000,000/$1,000,000.
• MDs should have coverage as follows: JUA/PCF combination or $1,000,000/$3,000,000.
  
  

Please ensure all information is enclosed and allow at least 30 days before calling to check on the status of your application. CBA can not process applications until it receives all information. Please retain a copy of all application materials for your records. All information you give in this application will be kept strictly confidential.

Companion Benefit Alternatives Practitioner Application

BlueChoice HealthPlan is a wholly owned subsidiary of BlueCross BlueShield of South Carolina and an independent licensee of the Blue Cross and Blue Shield Association.