Instructions for fax cover sheet - bcbsm.com · 2020. 9. 9. · Instructions for fax cover sheet We cannot accept handwritten forms. Do not hand write anywhere on the forms, otherwise

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:

o For individual practitioners From (Insert name of contact person) Date (MM/DD/YY) Type 1 National Provider Identifier State license number When adding an individual to an existing group, be sure to

a group change form

o For professional group practices and facilities From (Insert name of contact person) Date (MM/DD/YY) Type 2 NPI National Provider Identifier Tax identification number

o For group practices From (Insert name of contact person) Date (MM/DD/YY) Type 2 National Provider Identifier Tax identification number

Instructions for form 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) to1-866-900-0250. Be sure to fax the registration information separately foreach provider. (For example: If you register two or more providers, youmust send a fax for each provider. They cannot be bundled into one faxtransmission.)

Questions? Call 1-800-822-2761

WF 10584 MAR 19 Page 1 of 13

Blue CrossBlue ShieldBlue Care Networkof Michigan

FAX COVER SHEET FOR DOCUMENTS

IMPORTANT: Attach this page to the top of your documents toavoid processing delays.

Form Number:

Fax To:

From:

Date:

866-900-0250 Provider Enrollment

Mail to:

WF 10584 MAR 19 Page 2 of 13

Type 2 NPI:

Tax Identification Number:

10584

Provider EnrollmentBlue Cross Blue Shield of Michigan P.O. Box 217Southfield, MI 48034

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

GROUP CHANGE FORM

Group Change Form

Tax identification number Type 2 National provider identifier

PART B - Group member changes Add new group members – Section 10 Assign members to group's primary and additional practice locations – Section 11 Change a group member's primary practice location – Section 12 Change a group member's existing practice locations – Section 13 End a member's relationship with group – Section 14

Section 1: Change group name Current group name New group name

WF 10584 MAR 19 Page 3 of 13

Contact Information - Section 15

Application Signature - Section 16

Section 2: Change group EIN/Tax ID number and/or tax name Note: You must include IRS Form 147C or an IRS Tax Deposit Coupon as an attachment.

Current EIN/Tax name/DBA New EIN/Tax name/DBA

Tax exempt: Yes No

Section 3: Request additional group networks Requested effective date - The actual effective date will be determined based on the provisions in the applicable Participation/Affiliation Agreement(s). Your requested effective date cannot precede the date the group was formed as a bona fide legal entity. Important: Along with this application, it is necessary to complete and submit the appropriate signature document. 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. Select networks you are applying to:

Use this form for:PART A - Group changes Change group name – Section 1Change group EIN/TAX ID number and/or tax name – Section 2 Request additional group networks – Section 3Terminate group networks – Section 4Change group participation status – Section 5Change group primary, address – Section 6Changing medical records address – Section 6DChange Services – Section 7Adding a new group practice location – Section 8Closing a group practice location – Section 9

•

•

•

••

••

••

•

BCBSM networks Requested networks Traditional Traditional-Participating Traditional-Nonparticipating

(complete Group Signature Document) Requested effective date:

Vision

BCN networks Requested networks

BCN Commercial BCN Advantage SM HMO

Hearing

Vision-Participating Vision-Nonparticipating (complete Group Signature Document) Requested effective date:

Hearing-Participating Hearing-Nonparticipating (complete Group Signature Document) Requested effective date:

Group Change Form


Section 4: Terminate group networks Requested termination date - The actual date of your termination will be determined based on the provisions in the applicable participation agreements. Important: If you are terminating all networks, please complete the Group/Allied Provider Termination Form. Select networks you are terminating:

Requested termination date: Traditional Vision Hearing BCN Commercial BCN Advantage HMO

Select networks you are changing: BCBSM networks Requested participation change Traditional

(complete Group Signature Document) (effective 60 days upon receipt of request)

Vision

WF 10584 MAR 19 Page 4 of 13

Hearing

Medicare Plus Blue PFFSSM

Requested termination date:Requested termination date:Requested termination date: Requested termination date:Requested termination date:

SM

Section 5: Change group participation statusThe actual date of your participation status will be determined based on the provisions in the applicable participation agreement.

Traditional-Nonparticipating to Traditional-ParticipatingTraditional-Participating to Traditional-Nonparticipating


Vision-Nonparticipating to Vision-ParticipatingVision-Participating to Vision-Nonparticipating


Hearing-Nonparticipating to Hearing-ParticipatingHearing-Participating to Hearing-Nonparticipating

Section 6a: Change group primary addressPrimary office address (must be an address where health care services are rendered and may be published in BCBSM/BCN provider directories) Effective date:

Street address

City State ZIP code County

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

Telephone number Fax number

Monday Office hours

Open Close Open Close Open Close Open Close Open Close Open Close Open Close Tuesday Wednesday Thursday Friday Saturday Sunday

extension:

Website

http://www.bcbsm.com/pdf/WF_10586_group_allied_prov_term.pdf

Group Change Form


Effective date

Street address

City State ZIP code

Effective date

Street address

City State ZIP code

Page 5 of 13

Section 6b: Change payment/remit address

Section 6c: Change mailing address

Section 6d: Add or Change medical records addressAdding new medical records address Changing current medical records addressStreet Address

City State ZIP code

Contact Name - First Middle Last

Telephone Fax Email

Bone Density

Radiology Services: Add Remove

CT Scan

Radiation Oncology

Mobile Unit

MRI

Fluoroscopy

Nuclear Medicine

MRI of Breast

MRI - Open

Routine Xray

Ultrasound

Mammography

PET scan

Sleep Testing Services: AddAdd Remove

In-Center Sleep Testing

Section 7: Change Service: Change the services your group performs

Add Remove

Add Remove Home Testing

If you have selected 'Add', are you accredited by the If you have selected 'Add', are you accredited by the American Academy of Sleep Medicine? Yes No American Academy of Sleep Medicine? Yes No

WF 10584 MAR 19

If 'Yes' is selected, attach a copy of your AASM accreditation certificate. If it is not attached, your request may be denied.

If 'Yes' is selected, attach a copy of your AASM accreditation certificate. If it is not attached, your request may be denied.

Group Change Form


Page 6 of 13

Real-time online visit/e-visit

Check Counseling Services Provided

Mental Health Outpatient ServicesSubstance Use Outpatient Services

In an effort to help us match patient need to available providers, please identify a maximum of five (5) specialty areas of interest or certification. We will use this information in directing members for specific services. Our expectation is that your practice is open and accepting new cases if you indicate specialties below.

Select Five(5) TotalHigh Need Expertise Add Remove Add Remove

ADD/ADHD

AutismDementia/Alzheimer'sDisorders of Childhood & Adolescence

Dissociative DisordersEating Disorders

HIV/AIDS

Gambling Addiction

Neuropsychological Testing

Personality DisordersPsychological Testing

Psychotic Disorders

Sexual Addiction

Spending Addiction

Traumatic Brain Injury

BariatricBrief Dynamic TherapyCognitive Behavioral TherapyDialectical Behavioral Therapy

Exposure Response Prevention Therapy

Gender/Transgender Identification

Interpersonal Therapy

Obsessive Compulsive Disorders

Outpatient Transcranial Magnetic Stimulation

Pain Management

PhobiasPost Traumatic Stress Disorder

Sexual Dysfunction

Additional Special Areas Add Remove Add Remove

WF 10584 MAR 19

0-12(Child) 3-17 (Adolescent) 18-64 (Adult) 65+ (Geriatric) Other

LGBT Issues

Telemedicine Originating Site

Telemedicine Offered-audio and visual

Section 7: Change services - continued

Behavioral Health Services Select Age Ranges Treated:

All provider services: Add RemoveIn-home visitsIf adding, 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 officeTelehealth Services: Add Remove

Add Remove

Bereavement/Grief/Loss

Eye Movement Desensitization Reprocessing

Group Change Form


Section 8: Adding a new group practice location This information is required when adding a new practice location. Identify new address and all providers practicing at the new location. Must be an address where health care services are rendered and may be published in BCBSM and BCN provider directories.

List all providers practicing at the new location. First Name, Last Name, Degree Type 1 NPI If the new address is a Primary

address for a provider, please check box

1. PRI

2. PRI

3. PRI If you have additional providers or addresses to add, please list and attach separately.

If you have additional providers or addresses to close, please list and attach separately.

WF10584 MAR 19 Page 7 of 13

Effective date:

Street address


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

Monday Office hours

Open Close Open Close Open Close Open Close Open Close Open Close Open Close Tuesday Wednesday Thursday Friday Saturday Sunday

Effective date of closure:

Street address

City State ZIP code Telephone number

Section 9: Closing a group practice location This information is required when closing a practice location. Identify address and all providers who were practicing at that location.

List all providers who were practicing at the above address. If this location is a primary address for this provider, you must indicate a new Primary Address in Section 12.

First Name, Last Name, Degree Type 1 NPI

1.

2.

3.

WF 10584 MAR 19 Page 8 of 13

Degree NPIName (First name, Last Name)

List practice address #'s from Section 6a, where this provider practices (e.g., Primary, 1,2,3). Also check the appropriate box about each individual's practice location.

Practice Location # _______ Can a patient make an appointment to see this practitioner on a regular basis at this location? Yes NoDoes this practitioner cover or fill-in for colleagues within the same medical group on an as needed basis? Yes NoDoes this practitioner read tests or provide other services but does not see patients at this location? Yes No

Other:

Practice Location # _______ Can a patient make an appointment to see this practitioner on a Yes Noregular basis at this location?

Does this practitioner cover or fill-in for colleagues within the Yes Nosame medical group on an as needed basis?

Does this practitioner read tests or provide other services but does Yes Nonot see patients at this location?

Other:

Practice Location # _______ Can a patient make an appointment to see this practitioner on a regular basis at this location? Yes NoDoes this practitioner cover or fill-in for colleagues within the

Yes Nosame medical group on an as needed basis?Does this practitioner read tests or provide other services but does not see patients at this location? Yes No

Other:




Other:

Group Change Form


Part B - Group Member Changes

Note: Add new group members. If you have additional practitioners, please duplicate this page for each practitioner and respond to the questions indicated.

Section 10: Add new group members

Effective date of new group member: _______________________

Group Change Form


Section 10: Add new group members continued

WF 10584 MAR 19 Page 9 of 13

Degree NPIName (First name, Last Name)

List practice address #'s from Section 5, where this provider practices (e.g., Primary, 1,2,3). Also check the appropriate box about each individual's practice location.

Practice Location # _______ Can a patient make an appointment to see this practitioner on a regular basis at this location? YesYes No Does this practitioner cover or fill-in for colleagues within the same medical group on an as needed basis?basis? Does this practitioner read tests or provide other services but does

Yes Nonot see patients at this location?

Other:


Does this practitioner cover or fill-in for colleagues within the No Yes same medical group on an as needed basis?


Other:

Practice Location # _______ Can a patient make an appointment to see this practitioner on a regular basis at this location? YesYes No Does this practitioner cover or fill-in for colleagues within the

Yes Nosame medical group on an as needed basis?Does this practitioner read tests or provide other services but does

Yes Nonot see patients at this location?

Other:



Does this practitioner read tests or provide other services but does YesYes Nonot see patients at this location?

Other:

If you have additional practitioners, please duplicate this page for each one and respond to the questions as indicated.If applying to participate with Traditional, Vision, Hearing, BCN Commercial and/or BCN AdvantageSM

HMO, each group member must sign the Group Practice Agency Authorization and Acknowledgment form.It is understood that Group, its representative, or delegate is responsible for having each group member/individual practitioner execute the Group Practice Agency Authorization and Acknowledgment form. Group must retain copies of such executed form and to BCBSM upon request.

Effective date of new group member: _______________________

YesYes No

http://www.bcbsm.com/content/dam/public/Providers/Documents/enrollment/WF-14267-OCT14-GPAA.pdf

Group Change Form


Page 10 of 13

Note: if applying to participate with Traditional, Vision, Hearing, BCN Commercial and/or BCN Advantage HMO, each group member must sign the Group Practice Agency Authorization and Acknowledgement Form. It is understood that Group, its representative, or delegate s responsible for having each group member/individual practitioner execute theGroup Practice Agency Authorization and Acknowledgement Form. Group must retain copies of such executed form and provide to BCBSM upon request.

Section 11:Assign members to group’s primary and additional practice location This section must be completed if you are adding new members to your group. Please list the primary practice location and all additional practice locations where new members of your group practice. This information is required for Section 10. Note: This section is not used for adding new group practice locations. Use Section 8.

Primary Street address

City State ZIP code

#1 – Additional practice location Street address

City State ZIP code


City State ZIP code


City State ZIP code

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

Part B - Group Member Changes

Section 10: Add new group members continued

WF 10584 MAR 19

http://www.bcbsm.com/content/dam/public/Providers/Documents/enrollment/WF-14267-OCT14-GPAA.pdf

Group Change Form


Section 12: Change a group member’s primary practice location

If you need to change a group member’s primary practice location, please identify below. #1 Member - Current primary practice location

Can a patient make an appointment to see this practitioner on a regular basis at this location?

First name Last name Degree Type 1 NPI

Street address

City State ZIP code


New primary practice location

Street address



#2 Member - Current primary practice location


Street address

City State ZIP code


New primary practice location

Street address



WF10584 MAR 19 Page 11 of 13

No Yes If No, effective date of change:

Can a patient make an appointment to see this practitioner on a regular basis at this location? No Yes

Can a patient make an appointment to see this practitioner on a regular basis at this location? No Yes If No, effective date of change:

Can a patient make an appointment to see this practitioner on a regular basis at this location? No Yes

Group Change Form


Section 13: Change a group member's existing practice locations


Add practice location End practice location Effective date:

Street address

City State ZIP code

WF 10584 MAR 19 Page 12 of 13


Add practice location End practice location Effective date:

Street address

City State ZIP code

If you have additional practice that you want to change for current group members please list with the information requested above and attach separately.

Section 14: End a member's relationship with group Note: Identify group member(s) who are no longer with your group

First name, Last name, Degree Type 1 NPI Effective date of termination MM/DD/YY

Check here if physician was acting as a BCN

PCP

1.

2.

3.

4.

5.

If you have additional providers to terminate from your group, please list and attach separately.

Can a patient make an appointment to see this practitioner on a regular basis at this location? Yes No

Use this section to change additional practice address(es) for current group members.

Can a patient make an appointment to see this practitioner on a regular basis at this location? Yes No

Group Change Form


Section 15: Contact information *denotes a required field

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

*First name *Last name

*Phone number Fax number

E-mail Preferred method of contact?

E-mail U.S. Mail

I certify that the information contained in this application is true and complete.

Section 16: Application signature *denotes a required field

WF 10584 MAR 19 Page 13 of 13

*Print or type name of GroupRepresentative

*Group Representative Signature *Date

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.