instructions for fax cover sheet

WF 10582 DEC 21 of 14

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:

� For individual practitioners

� From (Insert name of contact person)

� Date (MM/DD/YYYY)

� Type 1 NPI (National Provider Identifier)

� 10 digit state license number

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

� For allied providers




� Tax identification number

� For professional group practices and facilities




� 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 10582 DEC 21 of 14

NEW GROUP ENROLLMENT FORM

FAX COVER SHEET FOR DOCUMENTS

IMPORTANT: Attach this page to the top of your document to avoid processing delays.

Fax To: 866-900-0250 Provider Enrollment

From:

Date:

Form Number: 10582

Type 2 NPI:

Tax Identification Number:

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

WF 10582 DEC 21 of 14

NEW GROUP ENROLLMENT FORMTax Identification Number Type 2 National provider identifier

Section 1: Demographic Data *denotes a required field

*Group name

*Group specialty

*County where your primary address is located

*Website

*EIN/Tax ID number

*EIN/Tax name as indicated on internal revenue service document

*Tax exempt Yes No

Are you a Retail-based Health Clinic? Yes NoAre you a Community Mental Health Center Yes NoAre you a Federally Qualified Health Center? Yes NoAre you an Indian Health Service Provider? If yes, are you limited to tribal members only?

Yes No Yes No

Are you a Student Health Services Provider? Yes NoAre you considered an Essential Community Provider under the Affordable Care Act?See Section 7 for additional information on participation? Yes No

Are you applying as an Urgent Care Center? Yes No

If you are an incorporated individual billing with your Type 2 NPI, you must also complete a New Practitioner Enrollment form to register your Type 1 NPI for billing purposes.

Section 2: Requested networksRequested effective date - The actual effective 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 the 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.Select networks you are apply to:

BCBSM networks Requested networks

Traditional Participating Nonparticipating Requested effective date:

Vision Participating Nonparticipating Requested effective date:

Hearing Participating Nonparticipating Requested effective date:

BCN networks Requested networksBCN Commercial

BCN AdvantageSM HMO

WF 10582 DEC 21 of 14


Section 3: 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/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

Mailing address

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 address Preferred method of contact?

Email US Mail

Medical Records Request (MRR)Street Address

City State Zip Code

Contact Name - First Middle Last

Telephone Fax Email

WF 10582 DEC 21 of 14


Section 3: Address data (continued)

Additional address - Accessibility

*Handicap accessibility: Yes No *Accessible by bus: Yes No

*Primary address - Office Hours

Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Open Time

Close Time

Does your group provide in-home visits? Yes No

Section 4: Services

Services: Select the services your group performs

Radiology Services:

Bone Density Mobile Unit Oncology

CT Scan MRI PET Scan

Diagnostic Testing MRI of Breast Read-only

Fluroscopy MRI - Open Routine Xray

Mammography Nuclear Medicine Ultrasound

Sleep Testing Services:

Home Testing If yes, are you accredited by the American Academy of Sleep Medicine?

In-Center Sleep Testing If yes, are you accredited by the American Academy of Sleep Medicine?

Yes No Yes No

Yes No Yes No

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

Telehealth Services:Select the following telehealth services you provide:

Telehealth Offered-audio and visual

Telehealth Originating Site

Real-time online visit/e-visit

WF 10582 DEC 21 of 14


Section 4: Services (continued)

Behavioral Health Services

Select Age Ranges Treated: 0-12 (Child) 3-17 (Adolescent) 18-64 (Adult) 65+ (Geriatric) Other:

Check Counseling Services Provided

Mental Health Outpatient Services

Substance 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 Additional Specialty Areas

AutismDementia/Alzheimer’sDisorders of Childhood & AdolescenceDissociative DisordersEating DisordersExposure Response Prevention TherapyNeuropsychological TestingPain ManagementPersonality DisordersPsychological TestingPsychotic DisordersTraumatic Brain Injury

ADD/ADHDBariatricBereavement/Grief/LossBrief Dynamic TherapyCognitive Behavioral TherapyDialectical Behavioral TherapyEye Movement Desensitization ReprocessingGambling AddictionGender/Transgender IdentificationHIV/AIDSInterpersonal TherapyLGBT IssuesObsessive Compulsive DisordersOutpatient Transcranial Magnetic StimulationPhobiasPost Traumatic Stress DisorderSexual AddictionSexual DysfunctionSpending Addiction

All providers services:In-home visitsIf 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: Acupuncture In-home only In-home and office

WF 10582 DEC 21 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.

#1

Street Address

City State ZIP Code

Telephone Number Fax Number




Open Time

Close Time

#2

Street Address

City State ZIP Code





Open Time

Close Time

#3

Street Address

City State ZIP Code





Open Time

Close Time

WF 10582 DEC 21 of 14


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

Name (First Name , Last Name) Degree NPI

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?Does this practitioner cover or fill-in for colleagues within the same medical group on an needed basis?Does this practitioner read tests or provide other services but does not see patients at this location?

Yes No

Yes No

Yes No

Other:

Primary Location #1


Yes No

Yes No

Yes No

Other:

Primary Location #2


Yes No

Yes No

Yes No

Other:

Primary Location #3


Yes No

Yes No

Yes No

Other:

Primary Location #4


Yes No

Yes No

Yes No

Other:

WF 10582 DEC 21 of 14


Section 6: Add group members (continued)

Name (First Name , Last Name) Degree NPI

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 #5


Yes No

Yes No

Yes No

Other:

Primary Location #6


Yes No

Yes No

Yes No

Other:

Primary Location #7


Yes No

Yes No

Yes No

Other:

Primary Location #8


Yes No

Yes No

Yes No

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 provide to BCBSM upon request.

WF 10582 DEC 21 of 14


Section 7: Group representative certification

The members of have certified. (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 conditions of the BCBSM Participation Agreement(s) signed on their behalf;

(2) That the name(s) and license information entered on this application are those of group members 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 10 days of group member enrollment changes, including additions and terminations of group members.

(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 Provider, 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 TRADITIONAL PRACTITIONER in instances where the PROVIDER is not eligible to participate in the TRUST network.

(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 PRACTITIONER in 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 agreement held by the provider that rendered the service.

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

Group representative signature: Date:

WF 10582 DEC 21 of 14


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 Number

Claims Tracking &

EFT

BCN PCP Claims

Summarye-Referral

Medical Drug PA

*Name

1.

*Telephone

*Name

2.

*Telephone

*Name

3.

*Telephone

*Name

4.

*Telephone

*Name

5.

*Telephone

WF 10582 DEC 21 of 14


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

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

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.

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

Provider Enrollment and Change Self-Service Access Request

Name (Type or Print name of each user) Telephone Number Provider Secured

Service 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

WF 10582 DEC 21 of 14

Section 10: Application signature

Have you ever been convicted of, pled guilty to, or nolo contendere to any felony?No Yes (Insert nature of offenses)

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?

No Yes (Insert nature of offenses)

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 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, copayments, or co-insurance amount, not balance bill the member for the difference between BCBSM’s payment and the provider’s charged amount.


WF 10582 DEC 21 of 14

Section 10: Application signature (continued)

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 along with this form?


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