Provider Secured Access Application FAX COVER PAGE

Fax To:

From (office):

Date:

SEP19

• We cannot accept handwritten forms.• Do not hand write anywhere on the forms(except for the signature), otherwise

processing will be delayed.• To ensure forms are processed timely, please adhere to the following instructions :

o Enter all information online(Google Chrome or Internet Explorer work best).o Press the tab key after each entry to move from field to field.

We’re always looking for ways to protect our member’s information and keep your account secure. That’s why we’d like to connect your online account to an email address that’s related to your business rather than a public email provider such as Hotmail, Gmail or Yahoo.

If you have a company email address, please include it on your request for access or changes to your Provider Secured Services account at bcbsm.com. If you’re not sure whether a company email address is available to you, check with your website administrator. Most websites offer a domain email free with your account. If you’re a smaller practice that doesn’t host a website, we’ll accept your request with the email you use to conduct your business.

PLEASE NOTE!!

**ATTENTION**

Contact:

Provider Secured Access ApplicationUsers cannot take their assigned IDs to other organizations.

Please complete electronically

Facility/Office Practice Name (where users are located) Provider Specialty

Street Address and Suite Number (address where users are located) Contact Person

City State Zip Code

Tax ID:

Contact Person's Telephone and Extension

Contact Person's company issued email address

Company issued email address to receive assigned Provider Secured Services ID(s):

Section 3. For offices that currently have access to e-referral and are requesting access for additional users, provide the Set ID or a User ID from office in Section 1.

Set/User ID

Section 4.

To view an example of a specific required code, place the mouse pointer in the center of the input field.

Assigned NPI Number(s)

Section 5.

BCN HMO and/or BCBSM Physicians

BCN Physician Organization

For individual providers, enter the Michigan state license number(s).

Enter the BCN IH Code(s)

BCBSM Physician Organization Name/ Identifier(s)

To obtain secured access user IDs, complete page 2 of this form.

1

WF 15607 SEP19

For Health e-Blue access, select the applicable network(s) below. Please note - Requesting Health e-Blue will add additional processing time

Section 2. Please add all NPIs from this existing User ID for the features requested by new user(s) in section 6. ID must be from office listed in Section 1.

• NPIs listed below in Section 4 are for new access for Provider Secured Services and e-referral.• All users receiving Claims Tracking & EFT access will automatically receive access to e-Referral.• To add NPI(s) to an existing e-referral set ID - submit the e-referral Request for Group ID Changes.

(http://www.bcbsm.com/content/dam/public/Providers/Documents/help/e-referral-id-group-changes.pdf)

• If requesting access to Medical Drug Prior Authorizations, please list type 1 NPI(s) below and check thebox for Medical Drug PA in Section 6.

• If additional space is needed, attach a separate listing of NPIs.

User ID

Check box if company issued email address is unavailable.

Section 1.

I hereby state the information provided on this application is correct and the provider/facility NPI(s) listed pertain to the facility only.

Signer's title

If the office does not have access to Provider Secured Services, submit a Use and Protection Agreement with this application.

Facility/Practice Name (Provider Name)

Section 6. Check ONLY the requested features for each user, if no features are selected the user will receive eligibility only access.

The following do not qualify for Medical Drug PA: DME, Billing Service, Immunization Pharmacies, and Home Infusion Therapy. You must bill using Professional Provider Codes.

Name (Type in full legal name for each user)

MANDATORY MANDATORY

Claims Tracking,

EFT

BCN PCP Claims

Summary

Health e-Blue (HEB)

Medical

Drug PA

Assigned Provider Secured Service ID (If BCBSM has assigned the user an ID)

Example: John Doe 248-222-1111 X X X X Example: F######

Section 7. Mandatory Authorization for use and access

I hereby state the information provided on this application is correct and the provider NPI(s) listed pertain to the provider only

Date

Type name of the authorized signer Signer's title

If there are questions, call 1-877-258-3932. Hours of operation: Monday-Friday 8 am-8 pm

To the extent you are applying for access as a provider, all confidentiality provisions contained in your Participating Hospital Agreement/Hospital Affiliation Agreement are applicable to every individual user granted secured access by this application.

I understand by signing this application I agree to only use and/or disclose BCN/BCBSM patient data for permissible treatment, payment and healthcare operation activities that allow me to service and care for my Blues patients. I also further agree that I will only use and/or disclose Medicare Advantage data to service and care for my Medicare Advantage patients.

By signing above, I represent that I am a Provider or the Authorized Representative and warrant that I have been granted full legal authority by corporate resolution, appropriate delegated signature authority, or as permitted by a signature policy, to enter into and bind the provider and/or provider group to contracts and agreements and intending to be legally bound have executed this agreement on the date above.

I addition, I understand that by signing above I have the company’s designated authority to request and maintain minimum necessary web access and am 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

Fax Application to 1-800-495-0812 © Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

2 WF 15607 SEP 19

Provider authorized signatureHandwritten signature only.

Provider Secured Access Application Users cannot take the assigned IDs to other organizations.

Please complete electronically

1.

2.

3.

6.

4.

5.

7.

8.

9.

10.

If additional space is needed, attach and sign additional page 2 (sections 6 & 7).

X

User's Business Telephone Number e-referral

ADDENDUM "G"

Practice or Facility Name Contact Person

Street Address and Suite Number Contact Person's Telephone and Extension

City State Zip Code Contact Person's company issued email address

Provider Group Name

Type 2 NPI(s)

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 F000000

Provider Enrollment and Change Self-Service Authorization

By signing below, 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 provider group to agreements. I understand, acknowledge, and attest that the user(s) listed on this Addendum 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.

Note: This is an Addendum to the Provider Secured Services Use and Protection Agreement and does not alter the terms set forth therein.

Name of Authorized Group Representative Title of Authorized Group Representative

Signature of Authorized Group Representative Handwritten signature only

Date

Please complete electronicallyAuthorization for Provider Enrollment and Change Self-Service

WF 16643 SEP 19 1

Section 1.

Section 3.

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.

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.

Section 4.

Fax to 800-495-0812 or for questions call 877-258-3932

Section 2.

Select one role