Acupuncturist Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Blue Cross Blue Shield of Massachusetts does not contract with or credential the alternative therapy practitioners listed below. However, our members can receive a 30% discount on alternative therapy providers who participate with WholeHealth Networks, Inc., a Tivity Health company.
For more information on becoming an in-network practitioner with WholeHealth Networks, Inc., a Tivity Health company please call their practitioner recruitment department at 1-800-274-7526. Or, visit their website.
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Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Provider Application
Important notes
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Before you enter the Provider Application, complete and save the required form for your provider type.
1 You must upload the Additional Site of Service form as an attachment when you fill out the Provider Application. 2 You must upload the Behavioral Health for Children and Adolescents (BHCA) form as an attachment when you fill out the Provider Application. You must include all their Massachusetts-licensed sites as well as the sites used for home-based BHCA services. |
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The Provider Application will prompt you to upload supporting documentation for your specialty. Please note:
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Be sure to click the "Yes" button on the final screen to submit your application: |
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Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Before you begin, complete and save the Behavioral Health for Children and Adolescents form. You will need to upload the form as an attachment when you fill out the Provider Application. You must include all your Massachusetts licensed sites as well as your sites used for home-based BHCA services.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Behavioral Health for Children and Adolescents form. You will need to upload the form as an attachment when you fill out the Provider Application. You must include all your Massachusetts licensed sites as well as your sites used for home-based BHCA services.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Fax this form with the requested documentation to 1-617-246-6819 or email to BlueCrossNetworkContracting@bcbsma.com.
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Certified Nurse Midwife Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
You may fill out the questionnaire online; however, you must either email or fax it to us. Our contact information appears on the form.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
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You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
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Clinical Specialist in Psychiatric and Mental Health Nursing Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Before you begin, complete and save the Behavioral Health for Children and Adolescents form. You will need to upload the form as an attachment when you fill out the Provider Application. You must include all your Massachusetts licensed sites as well as your sites used for home-based BHCA services.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
To enroll with us, please call Dental Network Management at 1-800-882-1178, Option 4. Or e-mail us.
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Hospital-based physicians (including Emergency Medicine, Radiologists, Anesthesiologists, Pathologists, and Nuclear Medicine) may contract with us without going through the credentialing process if they do not bill independently under separate tax identification number.
- The practitioner must submit a completed Integrated Mass Application (available at hcasma.org).
- The hospital must provide a letter confirming that the physician has been credentialed in accordance with 243 CMR 3.05. The letter must be addressed to Blue Cross and:
- Be less than one year old
- Describe any pending or closed healthcare facility or public agency disciplinary actions against the physician
- State that the physician’s privileges have not been altered due to direct or indirect concerns about his or her professional performance, judgment, or clinical skills.
Providers who have been enrolled as a non-credentialed hospital-based provider but who want to practice outside of the Emergency Room must become fully credentialed.
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
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Licensed Applied Behavior Analyst Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Licensed Dietitian Nutritionist Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
|---|---|
|
|
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
|---|---|
|
|
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
|---|---|
|
|
Nurse Practitioner Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
The following table explains how Nurse Practitioners and Physician Assistants contract with us.
| If you: | Then you can contract as an/a: | |||
|---|---|---|---|---|
| Render primary care | Have a collaborating or supervising physician who is listed with Blue Cross as a primary care physician | Maintain a panel of patients and manage their care | Render specialty care | |
|
Yes |
Yes |
Yes |
No |
NP-PCP (or PA-PCP) |
|
Yes |
Yes |
No |
No |
NP-primary care (or PA-primary care) |
|
No |
No |
No |
Yes |
NP-specialty care (or PA-specialty care) |
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Behavioral Health Nurse and Physician Assistant Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Nurse Practitioner Primary Care Provider Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
The following table explains how Nurse Practitioners and Physician Assistants contract with us.
| If you: | Then you can contract as an/a: | |||
|---|---|---|---|---|
| Render primary care | Have a collaborating or supervising physician who is listed with Blue Cross as a primary care physician | Maintain a panel of patients and manage their care | Render specialty care | |
|
Yes |
Yes |
Yes |
No |
NP-PCP (or PA-PCP) |
|
Yes |
Yes |
No |
No |
NP-primary care (or PA-primary care) |
|
No |
No |
No |
Yes |
NP-specialty care (or PA-specialty care) |
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
HCAS Provider Enrollment Form on HCASMA.org
Please fax your completed form to us at 617-246-4227.
We privilege providers who perform diagnostic imaging services. To learn how to apply to provide professional or technical services, go to our Privileging page.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Physician Assistant Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
The following table explains how Nurse Practitioners and Physician Assistants contract with us.
| If you: | Then you can contract as an/a: | |||
|---|---|---|---|---|
| Render primary care | Have a collaborating or supervising physician who is listed with Blue Cross as a primary care physician | Maintain a panel of patients and manage their care | Render specialty care | |
|
Yes |
Yes |
Yes |
No |
NP-PCP (or PA-PCP) |
|
Yes |
Yes |
No |
No |
NP-primary care (or PA-primary care) |
|
No |
No |
No |
Yes |
NP-specialty care (or PA-specialty care) |
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Psychiatric Nurse Practitioner Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Behavioral Health Nurse and Physician Assistant Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Physician Assistant Primary Care Provider Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Physician Assistant Primary Care Provider Fact Sheet - includes administrative requirements for PA-PCPs.
The following table explains how Nurse Practitioners and Physician Assistants contract with us.
| If you: | Then you can contract as an/a: | |||
|---|---|---|---|---|
| Render primary care | Have a collaborating or supervising physician who is listed with Blue Cross as a primary care physician | Maintain a panel of patients and manage their care | Render specialty care | |
|
Yes |
Yes |
Yes |
No |
NP-PCP (or PA-PCP) |
|
Yes |
Yes |
No |
No |
NP-primary care (or PA-primary care) |
|
No |
No |
No |
Yes |
NP-specialty care (or PA-specialty care) |
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
We privilege providers who perform diagnostic imaging services. To learn how to apply to provide professional or technical services, go to our Privileging page.
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Multi-specialty groups: You must apply for a separate group agreement for each specialty:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
- Psychiatrists and other licensed behavioral health clinicians
In addition, every practice member must submit a request to join the applicable group contract.
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
How to complete this application
| Complete ONLY pages 1-5 and the Clinical Profile if you are: | Complete the entire contracting application (including the Behavioral Health Professional Practice Application portion) if you are: |
|---|---|
|
|
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Speech Language Pathologist Contracting Application
You may fill out the contracting application online; however, you must either email or fax it to us. Our contact information appears on the form.
Please complete the TDI Privileging Application.
You may fill out the application online; however, you must either email or fax it to us. Our contact information appears on the form.
Be sure to submit your claims using the CMS-1500 claim form. Submitting claims with a UB-50 claim form will cause your claims to deny.
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Before you begin, complete and save the Additional Site of Service form. You will need to upload the form as an attachment when you fill out the Provider Application.
Complete the Provider Application online. You won't be able to save for later, so please fill out completely.
Provider Application
The Provider Application will prompt you to upload supporting documentation for your specialty.
Please note:
- We accept only these file types:
.pdf, .doc, .docx, .xls, .xlxs, .csv, .txt, .bmp, .gif, .jpeg, .png, .tiff
- Do not use periods in your file name. You can use spaces, dashes, and underscores, but no other special characters. For example:
- This file name would be accepted: Example_document-1.pdf
- This file name would NOT be accepted: Example.document.1.pdf
Be sure to click the "Yes" button on the final screen to submit your application:
Diagnostic imaging services
| If you | Then |
|---|---|
| Have professional privileges | No new professional privileging application is required. |
| Have technical privileges but are moving, adding a site, or joining a new practice | You must submit a Limited Technical Privileging Application for your new location. |
| Are not currently approved for either professional or technical privileging | Go to the Privileging page and download the applicable privileging application. |
