Instructions for fax cover sheet...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

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/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

o For allied providers

From (Insert name of contact person) Date (MM/DD/YYYY) Type 2 NPI National Provider Identifier Tax identification number

o For 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) 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 10582 OCT 20 Page 1 of 14

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:

Page 2 of 14

10582

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

NEW GROUP ENROLLMENT

Type 2 NPI:

Tax Identification Number:

WF 10582 OCT 20

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New Group Enrollment

Tax identification number Type 2 National provider number

Section 1: Demographic data *denotes a required field

*Group name

*Group specialty

*County where your primaryaddress is located

* EIN/Tax ID number

*EIN/Tax name as indicated oninternal revenue service document

If you are an incorporated individual billing with your Type 2 NPI, you must also complete a New Practitioner Enrollment form to register your Type1 NPI for billing purposes.

Section 2: Requested networks

Requ ested effective date - The ac tual e ffective date will be determined based on the provisions in the applicable Participation/Affiliation agreements. 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 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.

WF 10582 OCT 20 Page 3 of 14

Are you a Retail-based Health Clinic? Yes No Yes No

Are you a Community Mental Health Center? Yes No

*Tax exempt

Are you an Indian Health Services Provider? Yes No If yes, are you limited to tribal members only? Yes No

Are you a Federally Qualified Health Center? Yes No

Yes No Are you considered an Essential Community Provider under the Affordable Care Act?See Section 7 for additional information on participation. Are you applying as an Urgent Care Center? Yes No

Select networks you are applying to: BCBSM networks Requested networks Traditional Participating Nonparticipating

Requested effective date: Vision Participating Nonparticipating

Requested effective date: Hearing

BCN networks Requested networks

BCN Advantage HMOSM

Participating Nonparticipating Requested effective date:

BCN Commercial

* Website

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

Are you a Student Health Services Provider? Yes No

http://www.bcbsm.com/content/dam/public/Providers/Documents/enrollment/WF-10576-new-prac-enroll.pdf



Section 3: Address data *denotes a required field

*Primary office address (must be an address where health care services are rendered and maybe published in BCBSM/BCN provider directories)

*Street address

*City *State *ZIP code

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

*Primary telephone number Fax number

Payment address Street address

City State ZIP code

Street address

City State ZIP code

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

E-mail Preferred method of contact? E-mail U.S. Mail

Mailing address

Street Address

City State Zip Code

Contact Name - First Middle Last

Telephone Fax Email

WF 10582 OCT 20 Page 4 of 14

Medical Records Request (MRR)

Section 4: Services

Services: Select the services your group performs

Radiology Services:

Sleep Testing Services:


*Primary Address – Office Hours

Close Time

Open Time

Office Hour Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Section 3: Address data continued

Does your group provide in-home visits? Yes No

WF 10582 OCT 20 Page 5 of 14


Home Testing Yes No If yes, are you accredited by the American Academy of Sleep Medicine? Yes No

In-Center Sleep Testing Yes No If yes, are you accredited by the American Academy of Sleep Medicine? Yes No

Telehealth Services:Select the following telehealth services you provide:

Telemedicine Offered-audio and visualTelemedicine Originating Site Real-time online visit/e-visit

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

Bone Density

CT Scan

Diagnostic Testing

Fluoroscopy

Mammography

Mobile Unit

MRI

MRI of Breast

MRI - Open

Nuclear Medicine

Oncology

PET Scan

Read-only

Routine Xray

Ultrasound

Additional address - Accessibility

*Handicap accessibility Yes No *Accessible by bus Yes No

Page 6 of 14


Tax identification number Type 2 National provider identifier

Section 4: Services - continued

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

Check Counseling Services Provided

Mental Health Outpatient ServicesSubstance Use Outpatient ServicesIn 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) Total High Need Expertise Additional Specialty Areas

Select Age Ranges Treated:

Behavioral Health Services

AutismDementia/Alzheimer'sDisorders of Childhood & Adolescence Dissociative DisordersEating DisordersExposure Response Prevention Therapy Neuropsychological Testing

ADD/ADHDBariatricBereavement/Grief/LossBrief DynamicTherapy Cognitive Behavioral Therapy Dialectical Behavioral Therapy Eye Movement Desensitization Reprocessing Gambling Addiction Gender/Transgender Identification HIV/AIDS Interpersonal TherapyLGBT IssuesObsessive Compulsive Disorders Outpatient Transcranial Magnetic Stimulation PhobiasPost Traumatic Stress Disorder Sexual Addiction Sexual DysfunctionSpending Addiction

All provider services: In-home visits

In home only In home and office

WF 10582 OCT 20

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:

Pain Management Personality Disorders Psychological Testing Psychotic Disorders Traumatic Brain Injury



#1 Street address

City State ZIP code

Telephone number Fax number

#2 Street address

City State ZIP code


#3 Street address

City State ZIP code


Office hours

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Open time Close time

WF 10582 OCT 20

OCT 18

Page 7 of 14

Section 5: Additional practice locations (Must be an address where health care services are rendered and may be published in BCBSM and BCN provider directories)

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



Office hours





Office hours





Tax identification number


Type 2 National provider number

WF 10582 OCT 20 Page 8 of 14

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.

Primary 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:



Other:

Section 6: Add group members If you have additional practitioners, please duplicate this page for each practitioner and respond to the questions as indicated.

Tax identification number


Type 2 National provider number

Section 6: Add group members continued

WF 10582 OCT 20 Page 9 of 14

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? 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:




Other:



Other:




Other:

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 Acknowledgement Form. Group must retain copies of such executed form and provide to BCBSM upon request.

If applying to participate with Traditional, Vision, Hearing, BCN Commercial and/or BCN Advantage SM HMO, each group member must sign the Group Practice Agency Authorization and Acknowledgement

Form.

If you have additional practitioners, please duplicate this page for each one and respond to the questions as indicated.

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


Section 7: Group representative certification

The members of have authorized Name of group

Name of group representative

to act as agent and attorney in fact for all group members. The group representative, or his/her delegate, has express authority to submit claims for payment to BCBSM and/or BCN, and group members have given the representative authority to submit claims and receive payment on their behalf for covered services provided to BCBSM and/or BCN subscribers and members. It is understood and agreed that claims will be submitted only for covered services which are medically necessary, and only for services personally performed or personally supervised by and in the presence of a group member. In the event a BCBSM or BCN audit results in a recovery effort against any group member, the member and the group will be jointly and severally liable for that debt so long as the member was affiliated with the group on the dates of service included in the audit.

It is also understood that this is a continuing authorization and that data on claim forms are entered with the same authority, accuracy and effect as though executed by the group member providing the covered service. This authorization will remain in effect until terminated or modified by the representative’s written notice to BCBSM Provider Enrollment Department or by BCBSM and/or BCN upon written notice to the group representative.

If participating with BCBSM, I certify:

(1) That I have notified and obtained assent by group members to the terms and conditionsof the BCBSM Participation Agreement(s) signed on their behalf;

(2) That the name(s) and license information entered on this application are those of groupmembers for which a Group Provider Identification Number is to be issued and used, and

(3) I will notify BCBSM Provider Enrollment department in writing within 10days of group member enrollment changes, including additions and terminations of groupmembers.

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

Group representative signature: Date:


(4) That all of the group's shareholders are professionally licensed in at least one (1)of the professional services provided by the group.

If the group qualifies as an Essential Community Provide , the following apply:

(5) All providers within group are affiliated with BCBSM as a TRUST and SE Michigan Exclusive

Provider PRACTITIONER, if eligible for participation in that network or as a TRADITIONALPRACTITIONER in instances where the PROVIDER is not eligible to participate in the TRUSTnetwork.

(6) All new providers added to group will be affiliated with BCBSM as a TRUST PRACTITIONER,if eligible for participation in that network, or as a TRADITIONAL PRACTITIONERin instances where the PROVIDER is not eligible to participate in the TRUST network.

(7) That payment will be governed by the terms of the relevant individual affiliation agreementheld by the provider that rendered the service.

Page 10 of 14 WF 10582 OCT 20



Section 8: Provider Secured Services *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 AdministratorProvide 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.* Name (type or print) *Title

* Telephone Number *E-mail

* Does the practice currently use Provider Secured Services? Yes No

Provider Secured Services AccessComplete 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 (full legal name of each user)

*Telephone Numbere-Referral

Claims Tracking & EFT

* Name *Telephone number1.

* Name *Telehone number2.

* Name *Telephone number3.* Name *Telephone number

4. * Name *Telephone number

5.

BCN PCP ClaimsSummary

Medical Drug PA

WF 10582 OCT 20 Page 11 of 14



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

Enter the user ID(s) below to be updated with the NPI(s) indicated on this form.

WF 10582 OCT 20 Page 12 of 14

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

Complete Addendum “B” Authorization for Representative Access (PDF) to add NPI(s) to your existing Provider Secured Service ID.

Section 9: Provider secured services - Provider Enrollment Change Self Service - Addendum G Sign-up for ‘Provider Enrollment and Change Self Service’Provider Secured Service users can sign-up for access to Provider Enrollment and Change Self-Service. This service provides users the ability to perform on-line group information updates including: adding and removing practitioners, managing service locations, and enrolling new practitioners to your group. It also allows you to check the status of tasks in progress and see the current information related to your group.Provider Enrollment and Change Self-Service Basic Access: Allows users to maintain group demographics and composition only.

Provider Enrollment and Change Self-Service Full Access: Allows users to maintain group demographics and composition plus the ability to enroll and add new practitioners to the group.

Provider Enrollment and Change Self-Service Access Request

Name (Type or Print Full Name of Each User) Telephone Number Provider Secured

Services ID

Provider Enrollment and Change Self-

Service Basic Access

Provider Enrollment and Change Self-

Service Full Access

John Doe 111-222-3333 P000000 X X

Each transaction creates an audit trail and provides user controlled demographic changes with the ability to check the status of your change requests online anytime with a few mouse clicks.

http://www.bcbsm.com/content/dam/public/Providers/Documents/help/addendum-b-auth-rep-access.pdf

SECTION 10: Application Signature

3

*denotes a required field Has any member of the group ever been convicted of, pled guilty to, or pled nolo contendere to any felony? *(this is a required checkbox)


Page 13 of 14

In the past ten years, has any professional corporation, partnership, limited liability company or any other such entity in which you own an equity interest (directly or indirectly) and/or serve any management or leadership function (including, but not limited to, acting as a manager, board member, director, or executive) been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor or been found liable or responsible for any civil or criminal offense.*(this is a required checkbox)

*

*


WF 10582 OCT 20

No Yes (Indicate nature of offenses)

No Yes (Indicate nature of offenses)

I certify that the information contained in this application is true and complete. I will notify Blue Cross 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 Provider Enrollment and Change Self Service: I represent and warrant that I am an authorized group representative; I have been granted, by corporate resolution or otherwise, full legal authority to enter into and bind my providers to agreements. I understand, acknowledge, and attest that the user(s) listed in Section 9 – Addendum G have the authority to perform all transactions associated with the requested features on behalf of the Provider Group, Individual Provider, and/or Provider Organization, and that I (as the Provider Group, Individual Provider, and/or Provider Organization) am responsible for all actions undertaken by the listed individuals.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.

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

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

Ne w Group Enrollment


*Print or Type Name *Authorizing Signature/Title *Date

Before submitting,1) Have you completed Section 6 of this form?2) Have you completed the Group Signature Document and the SS-4, or IRS Payment Stub, to submit alongwith this form?

Page 14 of 14 WF 10582 OCT 20

SECTION 10: Application Signature continued *denotes a required field