Contracting, Enrollment, Credentialing & Demographic Changes

Enroll or Submit Changes Online! (For the best experience with the on-line forms, use Chrome)

Enroll or make changes to your existing information online, with our new online tools:

Online PROVIDER Enrollment/Change Form (PECF)

Online GROUP Enrollment/Change Form (GECF)


Please review the details and requirements related to each enrollment option.

For an overview of the tool, including required fields and how to attach required documentation, use the online enrollment tool quick reference guide.

Requirements

To be considered participating with Blue Cross and Blue Shield of Vermont or a designated entity, a group or individual must be enrolled, credentialed and hold a contract. Providers joining existing, contracted groups or individual providers entering into a contract with Blue Cross and Blue Shield of Vermont are not eligible to render services to any Blue Cross and Blue Shield member (including Federal Employee Program) until they are fully enrolled and approved by the credentialing committee.

What information are you looking for?


Provider Enrolling with a Group

You must complete and submit the following:

  • Provider Enrollment/Change Form (PECF) Online Form | Paper Form
  • A copy of your state licensure or certificate
  • Board Certification (MD and DO only)
  • Proof of malpractice/liability insurance
    • Minimum of $1m/$3m
  • Any applicable board certification or Drug Enforcement Agency license
  • National Provider Identifier (NPI)
  • Council for Affordable Quality Healthcare (CAQH) Credentialing Application using one of these two links:

Note: We are able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitioner's license. Indicate on the Provider Enrollment/Change Form (PECF) "pending" for license # in Section 4, Provider Information. 

 

Credentialing

You must complete a Council for Affordable Quality Healthcare (CAQH) Credentialing Application using one of these two links:

Click here to view the CAQH ProView® Profile Tip Sheet.

Credentialing Policies

Our credentialing policies define requirement, the process, credentialing and recredentialing criteria and rights and responsibilities. Links to the policies are below:

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Independent Provider

You must complete and submit the following:

  • Provider Enrollment/Change Form (PECF) Online Form | Paper Form
  • Group Practice Enrollment Change Form (GPECF) Online Form | Paper Form
  • W-9 Notes: 
    • We recommend you obtain a Tax Identification Number or EIN and NOT use a social security number as we are required to publish Tax Identification Numbers/EIN.
    • The name reported on the first line of the W-9 will be the name we issue your 1099s in and the name that will be listed in our on-line provider directory.
  • A copy of your state licensure or certificate
  • Board Certification (MD and DO only)
  • Proof of malpractice/liability insurance
    • Minimum of $1m/$3m
  • Any applicable board certification or Drug Enforcement Agency license
  • National Provider Identifier (NPI)
  • Council for Affordable Quality Healthcare (CAQH) Credentialing Application using one of these two links:

In addition to the above documents, a contract will be required. Call (888) 449-0443, option 2.

If you are a DENTAL PRACTICE, you may need to contact various companies for contracts, click here for details.

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New Group Practice with Associated Providers

To establish the group, you must complete and submit the following:

In addition to the above documents, a contract will be required. Call (888) 449-0443, option 2.

If you are a DENTAL PRACTICE, you may need to contact various companies for contracts, click here for details.

 

For each provider associated to the group, you must complete and submit the following:

  • Provider Enrollment/Change Form (PECF) Online Form | Paper Form
  • A copy of your state licensure or certificate
  • Proof of malpractice/liability insurance
    • Minimum of $1m/$3m
  • Any applicable board certification or Drug Enforcement Agency license
  • National Provider Identifier (NPI)
  • Council for Affordable Quality Healthcare (CAQH) Credentialing Application using one of these two links:

 

Note: We are able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitioner's license. Indicate on the Provider Enrollment/Change Form (PECF) "pending" for license # in Section 4, Provider Information.

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Enrollment of Locum Tenen

You must complete and submit the following:

  • Provider Enrollment/Change Form (PECF) Online Form | Paper Form
  • A copy of your state licensure or certificate
  • Proof of malpractice/liability insurance
    • Minimum of $1m/$3m
  • Any applicable board certification or Drug Enforcement Agency license
  • National Provider Identifier (NPI)

If the coverage will exceed 60 days:

Locum Tenens who will be covering for another provider for a period of 60 days or less do NOT require credentialing.

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Durable Medical Equipment

To initiate the contracting process, you must complete and submit the following:

  • Group Practice Enrollment Change Form (GPECF) Online Form | Paper Form
  • W-9
  • National Provider Identifier (NPI)
  • Proof of liability insurance
    • Minimum of $1m/$3m

All enrollment documentation must be submitted to :

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Non-Dispensing Pharmacist for Medication Therapy Management (MTM) Program

You must email Provider Contracting at providercontracting@bcbsvt.com and copy in our Clinical Pharmacist, Rita Baglini at baglinir@bcbsvt.com.

You will also need to follow the instruction above under "Provider Enrolling with a Group". On our Provider Enrollment and Change Form under the comment section note "MTM Pharmacist". 

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Demographic Changes

Group Practice or Independent Provider (private practice)

Change in address, NPI, tax identification number or a group name, please complete the following:

Change in provider name, please complete the following:

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Paper Forms

We highly recommend the online enrollment/change form option. However, if you wish to complete and mail in paper forms, you are welcome to do so using the forms below:

 

Where to submit completed enrollment forms and required documentation:

Type of ChangeWhere to Send
Durable Medical Equipment and
Laboratory Providers

 

Email: providercontracting@bcbsvt.com

All Other Changes

Fax: (802) 371-3489

Email: providerfiles@bcbsvt.com