Group Change Form

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:
o For individual practitioners
 From (Insert name of contact person)
 Date (MM/DD/YY)
 Type 1 National Provider Identifier
 State license number
 When adding an individual to an existing group, be sure to
a group change form
o For professional group practices and facilities
 From (Insert name of contact person)
 Date (MM/DD/YY)
 Type 2 NPI National Provider Identifier
 Tax identification number
o For group practices
 From (Insert name of contact person)
 Date (MM/DD/YY)
 Type 2 National Provider Identifier
 Tax identification number
Instructions for form 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
1-866-900-0250. 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 10584 MAY 16
Page 1 of 11
Blue Cross
Blue Shield
Blue Care Network
GROUP CHANGE FORM
of Michigan
FAX OR MAIL COVER SHEET
FOR DOCUMENTS
IMPORTANT: Attach this page to the top of your documents to
avoid processing delays.
Fax To:
866-900-0250 Provider Enrollment
From:
Date:
Mail to:
Form Number:
Provider Enrollment
Blue Cross Blue Shield of Michigan
P.O. Box 217
Southfield, MI 48034
10584
Type 2 NPI:
Tax Identification Number:
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association
WF 10584 MAY 16
Page 2 of 11
Group Change Form
Tax identification number
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•
•
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PART A - Group changes
Type 2 National provider identifier
Use this form for:
Change group name – Section 1
Change group EIN/TAX ID number and/or tax name – Section 2
Request additional group networks – Section 3
Terminate group networks – Section 4
Change group participation status – Section 5
Change group primary, address – Section 6
Changing medical records address – Section 6D
Change Services – Section 7
Adding a new group practice location – Section 8
Closing a group practice location – Section 9
•
PART B - Group member changes







Add new group members – Section 10
Assign members to group's primary and additional practice locations – Section 11
Change a group member's primary practice location – Section 12
Change a group member's existing practice locations – Section 13
End a member's relationship with group – Section 14
Contact Information - Section 15
Application Signature - Section 16
Section 1: Change group name
New group name
Current group name
Section 2: Change group EIN/Tax ID number and/or tax name
Note: You must include IRS Form 147C or an IRS Tax Deposit Coupon as an attachment.
New EIN/Tax name/DBA
Current EIN/Tax name/DBA
Tax exempt:
Yes
No
Section : Request additional group networks
Requested effective date - The actual effective date will be determined based on the provisions in the applicable
Participation/Affiliation Agreement(s). Your requested effective date cannot precede the date the group was formed as a
bona fide legal entity. Important: Along with this application, it is necessary to complete and submit the appropriate
signature document. 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 managed care networks. Select networks you are applying to:
BCBSM networks
Traditional
Requested networks
Traditional-Participating
Traditional-Nonparticipating
(complete Group Signature Document) Requested effective date:
Vision
Vision-Participating
Vision-Nonparticipating
(complete Group Signature Document) Requested effective date:
Hearing
Hearing-Participating
Hearing-Nonparticipating
(complete Group Signature Document) Requested effective date:
Requested networks
BCN networks
BCN Commercial
WF 10584 MAY 16
BCN Advantage
SM
HMO
Page 3 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 4: Terminate group networks
Requested termination date - The actual date of your termination will be determined based on the
provisions in the applicable participation agreements.
Important: If you are terminating all networks, please complete the Group/Allied Provider Termination Form.
Select networks you are terminating:
Requested termination date:
Requested termination date:
Requested termination date:
Requested termination date:
Requested termination date:
Requested termination date:
Traditional
Vision
Hearing
BCN Commercial
BCN Advantage SM HMO
Medicare Plus Blue SM PFFS
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The actual date of your participation status will be determined based on the provisions in the
applicable participation agreement.
Select networks you are changing:
BCBSM networks
Requested participation change
Traditional
Traditional-Nonparticipating to Traditional-Participating
Traditional-Participating to Traditional-Nonparticipating
(complete Group Signature Document)
(effective 60 days upon receipt of request)
Vision-Nonparticipating to Vision-Participating
Vision-Participating to Vision-Nonparticipating
(complete Group Signature Document)
(effective 60 days upon receipt of request)
Hearing-Nonparticipating to Hearing-Participating
Hearing-Participating to Hearing-Nonparticipating
(complete Group Signature Document)
(effective 60 days upon receipt of request)
Vision
Hearing
Section 6a: Change group primary address
Primary office address (must be an address where health care services are rendered and
may be published in BCBSM/BCN provider directories)
Effective date:
Street address
City
State ZIP code
County
Website
Address details
Primary telephone number must be a phone number patients can call to make an appointment.
Telephone number
Monday
extension:
Tuesday
Wednesday
Fax number
Thursday
Friday
Saturday
Sunday
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WF 10584 MAY 16
Page 4 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 6E: Change SD\PHQWUHPLWDGGUHVV
Effective date
Street address
City
State
ZIP code
State
ZIP code
Section 6c: Change mailing address
Effective date
Street address
City
Section 6d: Add or Change medical records address
Adding new medical records address
Changing current medical records address
Street Address
City
ZIP code
State
Contact Name - First
Middle
Last
Telephone
Fax
Email
Section 7: Change Service: Change the services your group performs
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Add
Add
Remove
Bone Density
MRI of Breast
CT Scan
MRI - Open
Radiation Oncology
Routine Xray
Mobile Unit
Ultrasound
MRI
Mammography
Fluoroscopy
PET scan
Remove
Nuclear Medicine
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Add
Remove
Add
Remove
Home Testing
In-Center Sleep Testing
If you have selected 'Add', are you accredited by the
American Academy of Sleep Medicine? Yes
No
If you have selected 'Add', are you accredited by the
American Academy of Sleep Medicine? Yes
No
WF 10584 MAY 16
Page 5 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 7: Change services - continued
Select Age Ranges Treated:
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18-64 (Adult) 65+ (Geriatric)
Other
Check Counseling Services Provided
Add Remove
Mental Health Outpatient Services
Substance Abuse Outpatient Services
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.
Select Five(5) Total
High Need Expertise
Add Remove
Add Remove
Add/ADHD
Autism
Dementia/Alzheimer's
Neuropsychological Testing
Personality Disorders
Disorders of Childhood & Adolescence
Psychotic Disorders
Dissociative Disorders
Eating Disorders
Sexual Addiction
Spending Addiction
HIV/AIDS
Traumatic Brain Injury
Psychological Testing
Gambling Addiction
Additional Special Areas
Add Remove
Add Remove
Bariatric
Obsessive Compulsive Disorders
Brief Dynamic Therapy
Cognitive Behavioral Therapy
Outpatient Transcranial Magnetic
Stimulation
Dialectical Behavioral Therapy
Pain Management
Phobias
Post Traumatic Stress Disorder
Exposure Response Prevention Therapy
Gender/Transgender Identification
Interpersonal Therapy
LGBT Issues
Sexual Dysfunction
Section 8: Adding a new group practice location
This information is required when adding a new practice location. Identify new address and all providers
practicing at the new location. Must be an address where health care services are rendered and may be
published in BCBSM and BCN provider directories.
All provider services:
In-home visits
WF 10584 MAY 16
Add
Remove
Page 6 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 8: Adding a new group practice location continued
This information is required when adding a new practice location. Identify new address and all providers
practicing at the new location. Must be an address where health care services are rendered and may be
published in BCBSM and BCN provider directories.
Effective date:
Street address
City
State
ZIP code
County
Primary telephone number must be a phone number patients can call to make an appointment.
Telephone number
Fax number
Friday
Saturday
Wednesday Thursday
Sunday
Open
Close
Open
Close
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Monday
Tuesday
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List all providers practicing at the new location.
First Name, Last Name, Degree
Type 1 NPI
If the new address is a Primary
address for a provider, please
check  box
1.
PRI
2.
PRI
3.
PRI
If you have additional providers or addresses to add, please list and attach separately.
Section 9: Closing a group practice location
This information is required when closing a practice location. Identify address and all providers who were
practicing at that location.
Effective date of closure:
Street address
City
State
ZIP code
Telephone number
List all providers who were practicing at the above address. If this location is a primary
address for this provider, you must indicate a new Primary Address in Section 12.
First Name, Last Name, Degree
Type 1 NPI
1.
2.
3.
If you have additional providers or addresses to close, please list and attach separately.
WF10584 MAY 16
Page 7 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Part B - Group Member Changes
Section 10: Add new group members
Note: If your group is participating with BCBSM and BCN, each new group member must return a
signed Group Practice Agency Authorization and Acknowledgment Form located at
http://www.bcbsm.com/provider/enrollment/ associated with their particular provider type, i.e., MD,
DO, CNP, CNM, CRNA, etc.
List group members to add:
*First name, Last name, Degree
*Type 1 NPI
*Effective date in
group
MM/DD/YY
*List practice address #’s
from Section 11, where
each provider practices
(e.g., Primary, 1, 2 or All)
1.
2.
3.
4.
5.
6.
Note: if applying to participate with Traditional, Vision, Hearing, BCN Commercial and/or BCN
Advantage HMO, each group member must sign the Group Practice Agency Authorization and
Acknowledgement Form. It is understood that Group, its representative, or delegate s responsible
for having each group member/individual practitioner execute the
Group Practice Agency Authorization and Acknowledgement Form. Group must retain copies of such
executed form and provide to BCBSM upon request.
Section 11:Assign members to group’s primary and additional practice location
This section must be completed if you are adding new members to your group. Please list the primary
practice location and all additional practice locations where new members of your group practice. This
information is required for Section 10.
Note: This section is not used for adding new group practice locations. Use Section 8.
Primary Street address
City
State
ZIP code
State
ZIP code
State
ZIP code
State
ZIP code
#1 – Additional practice location Street address
City
#2 – Additional practice location Street address
City
#3 – Additional practice location Street address
City
If you have additional practice locations, please list and attach separately.
WF 10584 MAY 16
Page 8 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 12: Change a group member’s primary practice location
If you need to change a group member’s primary practice location, please identify below.
#1 Member - Current primary practice location
Do you still practice at this location?
If No, effective date of change:
First name
No
Yes
Last name
Degree
Type 1 NPI
Street address
City
State
ZIP code
Telephone number
Fax number
New primary practice location
Street address
City
State
ZIP code
Telephone number
County
Fax number
#2 Member - Current primary practice location
Do you still practice at this location?
If No, effective date of change:
First name
No
Yes
Last name
Degree
Type 1 NPI
Street address
City
State
Telephone number
Fax number
ZIP code
New primary practice location
Street address
City
Telephone number
WF10584 MAY 16
State
ZIP code
County
Fax number
Page 9 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
Section 13: Change a group member's existing practice locations
Use this section to change additional practice address(es) for current group members.
First name
Last name
Degree
Type 1 NPI
Add practice location
End practice location Effective date:
Street address
City
State
First name
Add practice location
Street address
Last name
ZIP code
Degree
Type 1 NPI
End practice location Effective date:
City
State
ZIP code
If you have additional practice that you want to change for current group members please list with
the information requested above and attach separately.
Section 14: End a member's relationship with group
Note: Identify group member(s) who are no longer with your group
First name, Last name, Degree
Type 1 NPI
Effective date of
termination
MM/DD/YY
Check  here
if physician was
acting as a BCN
PCP
1.
2.
3.
4.
5.
If you have additional providers to terminate from your group, please list and attach separately.
WF 10584 MAY 16
Page 10 of 11
Group Change Form
Tax identification number
Type 2 National provider identifier
*denotes a required field
Section 15: Contact information
Note: Please provide the name and contact information of a person who can answer questions
about information in this application.
*First name
*Last name
*Phone number
Fax number
E-mail
Preferred method of contact?
E-mail
Section 16: Application signature
U.S. Mail
Click here for explanation
*denotes a required field
I certify that the information contained in this application is true and complete.
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.
When Completed
*Print or type name of Group
Representative
WF 10584 MAY 16
*Group Representative Signature
*Date
Page 11 of 11