Fillable Billing Service/ Third Party Management Access Application FAX (Blue Cross Blue Shield of Michigan)

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Billing Service/ Third Party Management Access Application FAX (Blue Cross Blue Shield of Michigan)

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Billing Service/
Third Party Management
Access Application
FAX COVER PAGE
Fax To:
From (office):
Date:
NOV 20
• 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:
WF 10904 NOV 20 Page 1
Billing Service/Third Party Management Name (where users are located)
Street Address and Suite Number (address where users are located)
City
State ZIP code
For office requesting additional Provider Secured Services ID’s
enter the User ID from this office to clone with the same NPI (s)
Note: If additional space is needed, attach a seperate listing of names and telephone numbers for each user requiring secured access.
Contact Person
Contact Person’s Telephone Number and Extension
Tax ID
Company Issued Email Address to receive Provider Secured Services ID(s)
Contact Person's Company Issued Email Address
For office that currently have access to e-referral and are
requesting access for additional users, provide the iExchange/SetID.
Provider Secured Services ID
Set
ID
Type the name(s) and phone numbers(s) of the individual(s) requiring Provider Secured Services Access, Check all features you are requesting
for each user. All individuals using Provider Secured Services must be included below to receive their own user ID. Provider Secured Services IDs
may not be shared among the office staff. For claims tracking and/or e-referral, each client (Provider/Facility) must complete an addendum B
Authorization for Representative Access Form.
Name (Type in full legal name for each user) User’s Telephone Number
Claims
Tracking
e-referral
Access
Assigned Provider Secured Service ID
(if BCBSM has assigned the user an ID)
Example: John B. Doe
248-222-1111
x x
Date
Billing Services Authorized Signature Handwritten Signature Only
Type name of authorized signer
Signer’s title
On behalf of the representing entity, the signer agrees they have the company’s designated authority. User IDs may not be shared. The
signer has authorized each individual employee to access Blue Cross Blue Shield of Michigan secured Provider Portal. Signer and their
authorized Users agree:
To use the data obtained only in the manner specified by Blue Cross Blue Shield of Michigan or Blue Care Network applicable agreements.
To certify any data obtained or submitted shall be for services performed by or under direct supervision of the Provider/Facility named
above.
To assure the information obtained or transmitted shall be confidential and used for the purpose of transacting BCBSM business.
In addition, I understand that by signing below 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 Billing Service/Third Party Management Use
and Protection Agreement. https://www.bcbsm.com/content/dam/public/Providers/Documents/help/billing-service-use-and-protection
agreement.pdf
I hereby state the information provided on this application is correct and the provider codes listed pertain to my practice/facility only.
Billing Service/Third Party Management Access Application
Please complete electronically
Fax Document to: 1-800-495-0812
If you have any questions, please call 1-877-258-3932
1.
2.
3.
4.
Check box if company
domain email address
is unavailable.
Section 1.
Section 2.
Section 3.
Section 4.
Section 5.
Section 1.
If NPI(s) should be added, list NPI(s) and User ID(s) below.
Provider or Group Name
NPI Number
Add to the below User IDs:
ID is either a P###### or F######
10-digit NPI Number
10-digit NPI Number
10-digit NPI Number
If NPI(s) should be removed, list NPI(s) and User ID(s) below.
Provider or Group Name
NPI
Number
Remove from the below User IDs:
ID is either a P###### or F######
10-digit NPI Number
Date
Type Name of the Authorized Signer
Title of Authorized Individual
Signature of Provider/Facility Authorized Individual
Handwritten Signature Only
For questions call 1-877-258-3932 Send Fax to 1-800-495-0812
WF16471 AUG 20
© Blue Cross Blue Shield of Michigan and Blue Care Network are a nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Billing Service/Service Bureau, TPA Name (where users are located)
Billing Service/Service Bureau, TPA Tax ID
Street Address and Suite Number (address where users are located)
Billing Service/Service Bureau, TPA Contact Person
City State Zip Code
Contact Person's Telephone
Contact Person's company issued email address
Extension
10-digit NPI Number
10-digit NPI Number
REMOVE NPI(s)
ADD NPI(s)
10-digit NPI Number
Tax ID
User ID
Tax ID
User ID
Tax ID
User ID
Tax ID
User ID
ADDENDUM "B" Authorization
Authorization for Representative Access to Provider Secured Services/e-referral Form
Please complete electronically
Authorization for Provider Secured Services and/or e-referral (To be completed by the Provider or the Authorized Representative for the provider/
facility).
This Authorization for Representative Access Form permits you to authorize a billing service or TPA to have access to designated information for your
indi
vidual and/or group provider NPI(s) for both Provider Secured Services and/or e-referral access.
The Billing Service, Service Bureau or TPA listed above, is authorized to access the information provided via Provider Secured Services and/or e-referral
either now or in the future, for both individual and/or group NPI(s) which is the minimum information necessary for performing their job function. If
the Authorized Representative's duties involve the use or disclosure of Protected Health Information (PHI), then the Health Insurance Portability and
Accountability Act of 1996, as amended (HIPAA), and stricter state and federal laws, as applicable, require the PHI be protected from inappropriate
uses or disclosures.
By signing below, I represent I am a Provider or the Authorized Representative for the Provider/facility and warrant I have been granted full legal
authority by corporate resolution to update BCBSM enrolled NPI(s) to Provider Secured Services login ID's and/or e-referral on the date set forth
below. If the signatory contractually represents multiple providers in the business of health insurance billing/inquiry, they must include a printout of all
such codes with this Addendum.
In addition, I understand that by signing below 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 Billing Service/Third Party Management Use and Protection
Agreement.
https://www.bcbsm.com/content/dam/public/Providers/Documents/help/billing-service-use-and-protection-agreement.pdf
Set ID
Section 2.
Section 3.
Section 4.
User ID
Remove NPI from all IDs
Tax ID
User ID
User ID
Check to also receive e-referral access
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Billing Service Third Party Management Access Application FAX (Blue Cross Blue Shield of Michigan)

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Completed 11 May 2021

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