Provider Forms

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Questions or need help? Contact provider service at (800) 924-3494.

Updated: 04/22/2020

Administrative

FormPurpose
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BlueCard Appeal Form
To appeal a confirmed denial of benefits
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COB Questionnaire for BlueCard Members
To file COB info on BlueCard members.
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Coordination of Benefits Questionnaire
When a patient is covered by more than one health plan
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Payment Inquiry Form
To inquire about a payment/claim
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Provider Overpayment Form
When you detect an overpayment

 

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Enrollment & Credentialing

FormPurpose
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Area of Expertise Form
Mental health and substance abuse clinicians must use this form to identify their area of expertise for marketing in both the on line and paper directories
CAQH Application for Credentialing Paper application for providers who don't want to file electronically
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Facility Credentialing
Defines the requirements for facilities
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Provider Enrollment/Change Form (PECF)
  • Add a new provider to the practice
  • Open/Close a patient panel
  • Changing address location
  • Termination of a provider
  • Changing a providers name
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Group Practice Enrollment/Change Form (GPECF)
  • Enrolling a new group practice
  • Enrolling an independent provider in private practice
  • Changing a Tax ID
  • Changing a NPI
  • Changing billing/physical/correspondence addresses
  • Changing the group name
Practitioner Credentialing Rights Provider rights during credentialing process
W9 Used to report income to IRS

 

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