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Instructions for fax cover sheet

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Instructions for fax cover sheet
We cannot accept handwritten forms. 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 group practices
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 document) 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 10575 JUL 20
Page 1 of 12
Blue Cross
Blue Shield
Blue Care Network
of Michigan
FAX COVER SHEET
FOR DOCUMENTS
IMPORTANT: Attach this page to the top of your documents to
avoid processing delays.
Form Number:
Fax To:
From:
Date:
866-900-0250 Provider Enrollment
Page 2 of 12
Type 1 NPI:
State License Number:
Type 2 NPI:
10575
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield AssociationBlue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association
NEW MENTAL HEALTH PRACTITIONER ENROLLMENT
WF 10575 JUL 20
Please complete this form if you are a psychiatrist, fully licensed psychologist, clinical licensed
master’s social worker, licensed professional counselor, licensed behavior analyst, licensed
marriage and family therapist, limited licensed psychologist, certified nurse practitioner or clinical
nurse specialist certified applying to Blue Cross Blue Shield of Michigan and Blue Care Network
for the first time.
Note: Your provider type is required to complete and maintain a credentialing application through
the Council for Affordable Quality Healthcare® at https://proview.caqh.org/pr. In order for your
managed care affiliation request to be processed you must complete your CAQH application
within 14 calendar days. If you have already completed a CAQH application, your attestation
must be up to date. If your CAQH application is not complete or if your attestation is expired after
14 calendar days, your request will be closed and you will need to reapply using the
Mental Health Practitioner Change form.
Section 1: Demographic data *denotes a required field
Race/Ethnicity
Black or African American
White/Caucasian
American Indian or Alaska Native
Chinese/Chinese-American
Asian
Filipino
Japanese/Japanese-American
Korean
Vietnamese
If registered with CAQH, CAQH ID number
*First name
Middle name
*Last name
Suffix
II III IV Jr. Sr.
*What type of provider
are you?
MD - psychiatrist
fully licensed psychologist
licensed professional counselor
*County where your primary addrerss is located
*Degree
*Date of birth
Gender
Male Female
Preferred salutation
Dr. Ms. Mrs.
Mr. Miss
Page 3 of 12
Native Hawaiian or other Pacific Islander
Mexican/Mexican-American
Hispanic/Latin American
Arab
Other Race
Assyrian/Chaldean
Other Asian
Multiracial
Not Disclosed
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
WF 10575 JUL 20
licensed marriage and family therapist
limited licensed psychologist
clinical licensed master’s social worker
DO - psychiatrist
clinical nurse specialist certified
licensed behavior analyst
(to treat patients with autism
spectrum disorder only)
certified nurse practitioner
Section 2: Individual Employer ID number /Tax information
*denotes a required field
*Social security number
*Is your EIN/Tax ID number the same as your
SSN?
Yes No (If no, enter Tax ID number below)
EIN/Tax ID Number
EIN/Tax name as indicated on IRS document
*Tax exempt
Yes No
If you are a practitioner joining a group, the group's tax id information needs to be added via a
New Group Enrollment form (for a new group) or a Group Change form for an existing group.
*denotes a required field
*Specialty
*
Board certified (MD, DO)
Yes No
Section 3: Specialty
New Mental Health
Practitioner Enrollment
State license number
Type 1 National provider identifier Type 2 National provider identifier
P
age 4 of 12
WF 10575 JUL 20
*
Board eligible (MD, DO)
Yes No
*
Do you practice exclusively in a hospital
setting? If yes, Section 1 of CAQH must be
updated to reflect hospital based status
(MD, DO)
Yes
No
Residency completed (MD, DO, DPM,
DMD/DDS)?
Yes No
If yes, residency completion date:
Note: Tax Information in this section applies to the individual practitioner's SSN or personal EIN
(for an incorporated individual business), not the group's information.
Medicare/PTAN number
Click here for explanation
Provider Type
Eligible Networks for Provider Type
Licensed Behavior Analyst
(to treat patients with autism spectrum disorder only)
Clinical Nurse Specialist Certified
Traditional-Participating
Traditional-Nonparticipating
Clinical Licensed Master Social Worker
Fully Licensed Psychologist
Psychiatrist
You will be notified of your status and the effective dates of affiliation in BCBSM and BCN managed care networks
after credentialing for the networks is completed and BCBSM and BCN have countersigned your affiliation
agreements. 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.
BCBSM and BCN do not permit retroactive effective dates in their managed care networks.
Select networks you are applying to:
Section 4: Requested networks
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
P
age 5 of 12
Certified Nurse Practitioner
Licensed Professional Counselor
Traditional-Participating
Traditional-Nonparticipating
TRUST PPO
BCBSM Mental Health and
Substance Abuse Managed Care Network
BCN Commercial
TRUST PPO
BCN Advantage HMO
SM
BCN Commercial
Traditional-Participating
Traditional-Nonparticipating
Medicare Advantage
SM
PPO
BCBSM Mental Health and
Substance Abuse Managed Care Network
Traditional-Participating
Traditional-Nonparticipating
Medicare Advantage
SM
PPO
BCBSM Mental Health and
Substance Abuse Managed Care Network
TRUST PPO
BCBSM Mental Health and
Substance Abuse Managed Care Network
WF 10575 JUL 20
T
raditional-Participating
T
raditional-Nonparticipating
Medicare Advantage
SM
PPO
Traditional-Participating
Traditional-Nonparticipating
Licensed Marriage and Family Therapist
Limited Licensed Psychologist
T
raditional-Participating
T
raditional-Nonparticipating
TRUST PPO
Medicare Advantage
SM
PPO
BCBSM Mental Health and
Substance Abuse Managed Care Network
Section 5: Address data
*denotes a required field
Primary office address (must be an address where health care services are rendered and may
be
publishe
d 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
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
Page
6 of 12
Medical Records Request (MRR)
Street Address
City
State Zip code
Contact Name - First
Middle Last
Telephone
Fax Email
Payment/Remit address
Street address
City State ZIP code
Mailing address (If different from your primary address)
Street address
City State ZIP code
WF 10575 JUL 20
Section 5: Address data - continued
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
Fax number
Work email address
Preferred method of contact?
E-mail
U.S. Mail
Primary Address – Office
Office
Hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open
time
Close
time
Page 7 of 12
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
extension:
0-
12
(Child)
13-17 (
Adolescent)
18-64 (
Adult)
65+
(Geriatric)
Other _________________
Check Counseling Services Provided
Mental Health Outpatient Services
Substance Us
e Outpatient
Services
WF 10575 JUL 20
Select Age
Ranges Treated:
Behavioral Health Services
Telehealth Services
Telemedicine Offered-audio and visual
Telemedicine Originating Site
Real-time online visit/e-visit
Section 6: Services
Select the following Telehealth services you provide:
Additional address - Accessibility
*Handicap accessibility Yes No *Accessible by bus Yes No
Click here for explanation
Page 8 of 12
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
Select Five (5) Total
High Need Expertise Additional Specialty Areas
ADD/ADHD
Bariatric
Autism
Br
ief Dyna
mic T
he
r
a
p
y
Dementia/Alzheimer’s
Cognitive Behavioral Therapy
Disorders of Childhood & Adolescence
Dialectical Behavioral Therapy
Dissociative Disorders
LGBT Issues
Eating Disorders
Gender/Transgender Identification
HIV/AIDS
Interpersonal Therapy
Gambling Addiction
Obsessive Compulsive Disorders
Neuropsychological Testing
Outpatient Transcranial Magnetic Stimulation
Personality Disorders
Pain Management
Psychological Testing
Phobias
Psychotic Disorders
Post Traumatic Stress Disorder
Sexual Addiction
Sexual Dysfunction
Spending Addiction
Suboxone Treatment Opiate Addiction (STOA) *
All provider services:
□ In-home visits
Section 6: Services - continued
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.
Exposure Response Prevention Therapy
WF 10575 JUL 20
Bereavement/Grief/Loss
Eye Movement Desensitization Reprocessing
Medication Assisted Treatment
for Opioid Use (MATO) *
Traumatic Brain Injury
* If you provide MATO / STOA Services, you must include a copy of your certification.
Section 7: Additional practice locations
(Must be an address where health care services are rendered and may be published in
BCBSM/BCN provider directories)
#1 Street
address
City State ZIP code
Telephone number Fax number
Office
hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open
time
Close
time
#2 Street address
City State ZIP code
Telephone number Fax number
Office
hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Open
time
Close
time
Practitioner Enrollment
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
P
age 9 of 12
WF 10575 JUL 20
Additional address - Accessibility
*Handicap accessibility Yes No
*Accessible by bus
Yes No
Additional address - Accessibility
*Handicap accessibility Yes No
*Accessible by bus Yes No
Section 8: Provider secured services – web-DENIS *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 Administrator
Provide 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 Access
Complete 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.
(full legal name of each user)
*Telephone Number
Claims
Tracking
&
EFT
* Name *Telephone number
1.
* Name *Telephone number
2.
* Name *Telephone number
3.
BCN
PCP
Claims
Summary
Medical
e-Referral
Drug PA
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
Practitioner Enrollment
Page 10 of 12
* Name *Telephone number
4.
* Name *Telephone number
5.
* Name *Telephone number
6.
* Name *Telephone number
7.
* Name *Telephone number
8.
WF 10575 JUL 20
* Name
Click here for explanation
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.
New Mental Health
State license number
Type 1 National provider identifier Type 2 National provider identifier
Practitioner Enrollment
Page 11 of 12
WF 10575 JUL 20
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)
In the past ten years have you been convicted of, pled quilty to, or pled nolo contendere to any
misdemeanor (excluding minor traffic violations) or been found liable or responsible for any
civil offense that is reasonably related to your qualifications, competence, function, or duties
as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?
No
Yes (Insert nature of offenses)
Section 9: Application signature
*Print or Type Name
*Practitioner Signature/Title *Date
WF 10575 JUL 20
Page 12 of 12
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.
State license number
Type 1
National provider identifier Type 2 National provider identifier
New Mental Health
Practitioner Enrollment
Section 9: Application signature continued
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 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 G
uidelines
for Non-Participating Providers. These Guidelines include, without limit
ation, 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.
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Instructions for fax cover sheet

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Completed 8 February 2021

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