Enrollment Practitioner Form – Fill Out and Use This PDF

Instructions for fax cover sheet

We cannot accept handwritten forms. Do not hand write anywhere on the forms, otherwise processing will be delayed.

To ensure forms are processed timely, please adhere to the following instructions:

Enter all information online; press the tab key	after each entry to move
from field to field.

OFor individual practitioners

From (Insert name of contact person)

Date (MM/DD/YYYY)

Type 1 National Provider Identifier

State license number

When adding an individual to an existing group, be sure to fax a group change form

OFor allied providers

From (Insert name of contact person)

Date (MM/DD/YYYY)

Type 2 NPI National Provider Identifier

Tax identification number

OFor professional group practices and facilities

From (Insert name of contact person)

Date (MM/DD/YYYY)

Type 2 National Provider Identifier

Tax identification number

Instructions for document submission

1.Fax cover sheet must be the first page of your form submission.

2.Fax the registration form and attachments (i.e., signature documents) to

1-866-900-0250. Be sure to fax the registration information separately for each provider. (For example: If you register two or more providers, you must send a fax for each provider. They cannot be bundled into one fax transmission.)

Questions? Call 1-800-822-2761

WF 10576 JUL 20

Page 1 of 11

Fax To:

866-900-0250 Provider Enrollment

From:

Date:

Form Number:

10576

Type 1 NPI:

State License Number:

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association

WF 10576 JUL 20	Page 2 of 11

New Practitioner Enrollment

Please complete this form if you are an MD, DO, DC, DPM, DMD/DDS (board certified oral surgeon only), independent physical therapist, independent occupational therapist or independent speech language pathologist applying to Blue Cross Blue Shield of Michigan/Blue Care Network for the first time.

Note: You are required to complete and maintain a credentialing application through the Council for Affordable Quality Healthcare® at https://proview.caqh.org/pr In order for your managed care affiliation

request to be processed you must complete your CAQH application within 14 calendar days. If you have already completed CAQH application, your attestation must be up to date. If your CAQH application is not complete or if your attestation is expired after 14 calendar days, your request will be closed, and you will need to reapply using the Practitioner Change form.

Section 1: Demographic data			*denotes a required field
*First name
Middle name
*Last name
Suffix		□ II □ III □ IV □ Jr. □ Sr.
*What type of provider are		□ MD □ DO □ DC □ DPM □ DMD □ DDS IPT IOT ISLP
you?
*County where your
primary address is located
*Degree
*Date of birth
Gender		□ Male	□ Female
Preferred salutation		□ Dr. □ Ms.	□ Mrs. □ Mr. □ Miss
Race/Ethnicity
White/Caucasian			Native Hawaiian or other Pacific Islander
Black or African American			Mexican/Mexican-American
American Indian or Alaska Native			Hispanic/Latin American
Asian			Arab
Chinese/Chinese-American			Other Race
Filipino			Assyrian /Chaldean
Japanese/Japanese-American			Other Asian
Korean			Multiracial
Vietnamese			Not Disclosed

If registered with CAQH, CAQH ID number

WF 10576 JUL 20

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						New Practitioner Enrollment
State license number				Type 1 National provider identifier
Section 2: EIN/Tax information						*denotes a required field

Note: You must include IRS Form 147c or IRS Tax Coupon as an attachment.

*Social Security number
*Is your EIN/Tax ID number the same as your	□ Yes □ No (If no, enter Tax ID number
SSN?	below)
EIN/Tax ID number
EIN/Tax Name as indicated on IRS document
*Tax exempt	□ Yes □ No
Medicare/PTAN number:

If you would like to bill with your Type 2 NPI (National provider identifier) representing your incorporated individual business, you must also complete a New Group Enrollment form to register this entity as a group.

Section 3: Primary specialty

*denotes a required field

*Specialty

If your specialty is Adolescent Medicine, Family Medicine, Geriatric Medicine - Family Practice, Geriatric Medicine, General Practice, Internal Medicine, Pediatrics, Public Health / General Preventive Medicine, or Preventive Medicine, are you functioning as a

Primary Care Physician (PCP) or a	Specialty Care Physician (SCP)
*Board certified (MD, DO, DMD, DPM, DDS only)		Yes No

WF 10576 JUL 20	Page 4 of 11

New Practitioner Enrollment

State license number	Type 1 National provider identifier

Section 4: Requested networks

You will be notified of your status and the effective dates of affiliation in BCBSM and BCN managed care networks after credentialing for the networks is completed and BCBSM and BCN have countersigned your affiliation agreements. Important: Along with this application, it is necessary to complete and submit the signature document appropriate for your provider type. For each network you wish to participate in, be sure to place a check mark by the appropriate affiliation agreement, sign the signature document, and submit it along with this form.

BCBSM and BCN do not permit retroactive effective dates in managed care networks.

If you are a specialist billing with a Type 2 NPI, BCN contracts with the Group Practice. Please follow the instructions on the website for Professional Group Enrollment.

Select networks you are applying to:

Provider Type

Eligible Networks for Provider Type

Doctor of Medicine

Traditional-Participating

TRUST PPO

Doctor of Osteopathy

Traditional-Non Participating

Blue Preferred Plus

Medicare Advantage SM PPO

Vision/Hearing (if applicable)

Chiropractor

Traditional-Participating

Medicare Advantage SM PPO

Podiatrist

Traditional-Non Participating

Blue Preferred Plus

Oral Surgeon

TRUST PPO

Independent Physical Therapist

Traditional-Participating

BCN Commerical

Independent Occupational Therapist

Traditional-Non Participating

Blue Preferred Plus

Medicare Advantage SM PPO

TRUST PPO

BCN Advantage SM HMO

Independent Speech

Traditional-Participating

BCN Commerical

Language Pathologist

Traditional-Non Participating

Blue Preferred Plus

Medicare Advantage SM PPO

TRUST PPO

BCN Advantage SM HMO

BCN Primary Care Physicians

Select the Network (s) to which you are applying:

BCN Advantage SM HMO

BCN Commercial

Please provide the name of the medical care

Medical care group name:

group and number you wish to join.

Medical care group number:

WF 10576 JUL 20

Page 5 of 11

New Practitioner Enrollment

Section 5: Address data

*denotes a required field

Primary office address (Must be an address where health care services are rendered and may be published in BCBSM and BCN provider directories)

*Street address

Primary telephone number must be a phone number patients can call to make an appointment

Payment/Remit address

Street Address

Mailing address

Street Address

Medical Records Request (MRR)

Street Address

WF 10576 JUL 20

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New Practitioner Enrollment

Section 5: Address data – continued

*denotes a required field

Contact information

Please provide the name and contact information of a person who can answer questions about information in this application

*First name

*Last name

*Telephone number

extension:

Fax number

Work email address

Preferred method of contact?

□ E-mail □ U.S. Mail

Additional address - Accessibility

*Handicap accessibility

Yes

No

*Accessible by bus

Yes

No

*Primary address – Office hours

Office

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

hours

Open

time

Close

time

Section 6: Services

All provider services:

In-home visits

If you provide in-home visits, please indicate below if you practice exclusively in the home setting or

if you also provide care in an office setting: In home only In home and office

Lactation counseling

Occupation Therapist, Physical Therapist, Speech Language Pathologist Services:

Autism service		Add		Remove

Telehealth Services:

Telemedicine Offered-audio and visual

Telemedicine Originating Site

Real-time online visit/e-visit

WF 10576 JUL 20

Page 7 of 11

New Practitioner Enrollment

State license number	Type 1 National provider identifier

Section 7: Additional solo practice locations (Must be an address where health care services are rendered and may be published in BCBSM and BCN provider directories)

Additional address - Accessibility

*Handicap accessibility

Yes

No

*Accessible by bus

Yes

No

Office

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours

Open

time

Close

time

#2 Street address

City

State

Zip code

Telephone number

Fax number

Additional address - Accessibility

*Handicap accessibility

Yes

No

*Accessible by bus

Yes

No

Office

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours

Open

time

Close

time

#3 Street address

City

State

Zip code

Telephone number

Fax number

Additional address - Accessibility

*Handicap accessibility Yes

No

*Accessible by bus

Yes

No

Office

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

hours

Open

time

Close

time

If you have additional locations, please list and attach separately.

WF 10576 JUL 20

Page 8 of 11

New Practitioner Enrollment

State license number	Type 1 National provider identifier

Section 8: Provider secured services – web-DENIS *denotes a required field

Doing business electronically saves your office time and money. We encourage you to sign up for

Provider Secured Services, a free service for BCBSM and BCN participating providers that allows

you to view patient eligibility, track claims, and much more online. Begin the process by completing

the information in the section below:

Existing Provider Secured Service users that would like to update their access to include the NPI (s) indicated on this form complete:

Section 8A: Professional/Facility Providers - Authorization to update user access for Provider Secured Services

Section 8B: Billing Services - Authorization to update user access for Provider Secured Services

Authorized Web Access Administrator

Provide the name and contact information of the person who is the authorized Web Access Administrator

with delegated authority to manage all access to protected health information and group practitioner records using provider secured (web) self services.

Provider Secured Services Access

Complete the section below for individuals that do not have an existing Provider Secured Services

(web-DENIS) login ID. Only check off the minimum necessary features for each user listed below.

* Name

Claims

BCN

e-Referral

Medical

Tracking

PCP

Drug PA

(full legal name of each user)

&

Claims

*Telephone Number

EFT

Summary

* Name

*Telephone number

1.

* Name

*Telephone number

2.

* Name

*Telephone number

3.

* Name

*Telephone number

4.

* Name

*Telephone number

5.

WF 10576 JUL 20

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New Practitioner Enrollment

Section 9: Application signature continued

I certify that the information contained in this application is true and complete. I will notify Blue Cross and Blue Shield of Michigan and Blue Care Network immediately in writing of changes affecting this data. If I am a practitioner in training, I will not report services that are related to my training program and rendered at the address from which I am training. Should I re-enter training,I will notify BCBSM and BCN.

In addition, the authorized signer agrees that he/she has the company's designated authority to request and maintain minimum necessary Web access and is responsible for complying with all terms and conditions contained within the Provider Secured Services Use and Protection Agreement.

(https://www.bcbsm.com/content/dam/public/Providers/Documents/help/faqs/use-and-protection-agreement- professional-facility.pdf)

For providers applying to be Traditional non-participating providers, the authorized signer agrees on behalf of itself and the provider on whose behalf the authorized signer is acting, to adhere to BCBSM’s Billing Guidelines for Non-Participating Providers. These Guidelines include, without limitation, the requirement to permit BCBSM or its designee physical access to the provider’s premises to review and/or copy for any permissible purpose any and all medical and billing records submitted by the provider or its billing agent, and the requirement that the provider accept BCBSM’s payment as payment in full for services rendered to a BCBSM member when the provider has indicated that it will accept assignment of payment on the member’s behalf, will participate with BCBSM on a particular claim, or has otherwise indicated that he/she wishes to receive payment directly from BCBSM and, with the exception of any applicable deductibles, co-payments, or co-insurance amount, not balance bill the member for the difference between BCBSM’s payment and the provider’s charged amount.

WF 10576 JUL 20	Page 11 of 11