Fillable Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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WF 18140 JUN 20
Page 1 of 5
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:
Enter all information on-line; press the tab key after each entry to move from
field to field.
o For individual practitioners
From (Insert name of contact person)
Date (MM/DD/YYYY)
Type 1 National Provider Identifier
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
1-800-900-0250. 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).
Please complete the following:
1. Complete a Signature Document for your Provider Type
2. Please submit all required documentation with your enrollment application. The
required documentation for your enrollment can be found at:
https://www.bcbsm.com/providers/join-the-blues-network/join-provider-network.html
3. Please include CAQH ID
4. Do not submit your BCBSM application until you have enrolled with CAQH first
Questions? Call 1-800-822-2761
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
Type 1 NPI:
18140
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
BCBSM/CAQH Supplemental Enrollment Form
Page 2 of 5
WF 18140 JUN 20
State License Number:
Page 3 of 5
BCBSM/CAQH Supplemental Enrollment Form
State License Number Type 1 National Provider Identifier
Please complete this form after you have been approved with CAQH. Your CAQH ID is required to
process this application for enrollment.
Note: You are 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 the 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 re-apply using the Practitioner Change Form.
Section 1: Demographic data * denotes a required field
*First Name
*Middle Name
*Last Name
*CAQH ID
BCBSM/ BCN does not permit retroactive effective dates.
Traditional – Non Participating
TRUST PPO
BCN Commercial
Traditional – Participating
Medicare Plus Blue PPO
Medicare Supplemental
BCN Advantage HMO
BCBSM
BCN
BCBSM
Medicare
Advantage
Medicare
DME
Medicare
Medicaid
Electronic
Remittance
Internet browser and version
Hardware and Operating system
WF 18140 JUN 20
Section 2: Requested Networks
You will be notified of your enrollment status when the process is complete.
Section 2A: Internet Claims Tool
If you would like to submit electronic claims through our provider Web portal (webDENIS), complete
section 6 and section 7.
BCBSM/ BCN Requested Networks
Check the payers and remittance report you would like to sign up for
SM
SM
Page 4 of 5
BCBSM/CAQH Supplemental Enrollment Form
State License Number Type 1 National Provider Identifier
Section 3: 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 complimentary service for BCBSM/ BCN participating providers that allows you to view patient eligibility,
track claims and much more on-line. Begin the process by completing the information in the section below.
Authorized Web Access Administ
rator
Provid
e t
he nam
e and contact
informati
on of
t
he perso
n wh
o is
t
he authoriz
ed 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 *Title
*Telephone Number
*E-mail address
*Does the individual named above currently use
Provider Secured Services (webDENIS)?
Yes No
*If yes, indicate the individual’s Provider Secured
Services user ID.
*User ID
Provider Secured Services Access
Complete the section below for individual(s) that do not have an existing Provider Secured Services (webDENIS)
log-in ID. Only check the minimum necessary features for
each user listed below.
*Name (full legal name of each user)
*Telephone Number and *E-mail address
Eligibility
Coverage
Claims
Tracking
BCN PCP
Claims
Summary
Provider
Claim
Correction
Internet
Claims
Tool
1. *Name
*Telephone
*E-mail Address
2. *Name
*Telephone
*E-mail Address
3. *Name
*Telephone
*E-mail Address
4. *Name
*Telephone
*E-mail Address
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 Service Use and Protection Agreement.
*Authorized Signature
*Date
Complete the Provider Secured Service Use and Protection Agreement and return with the application.
If you have additional user names, please list and attach separately with access features denoted.
WF 18140 JUN 20
Page 5 of 5
State License Number Type 1 National Provider Identifier
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 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)
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 l
eadership 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 BlueShield
of Michigan and Blue Care Network immediately in writing of changes affecting this data. If I am a practitioner in
traini
ng, 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.
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.
WF 18140 JUN 20
BCBSM/CAQH Supplemental Enrollment Form
*Print or Type Name
*Date
*Signature/Title
Section 4: Application signature
When Completed
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Instructions for fax cover sheet (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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