Accepting new patients verification

In order to help our members find BCBSND participating providers that are accepting new patients, we are asking you to assist us with keeping our provider directory up to date. If you have had a recent change in whether or not you are accepting new patients at any location, please complete the form below and we will update your file.

Accepting New Patients Update Form

Appeals

Appeal forms should not be used to submit a claim correction, medical records, or EOBs.

Prefer to print form and submit?
Provider Appeals Form

Authorized referral

Please note: Submit through Availity Essentials on the Referrals page

Comprehensive orthodontic treatment plan

Coordination of Benefits (COB) Questionnaire form

If a provider is aware of a member having additional coverage, they can utilize this form. 

Providers have the choice to:

  • Instruct the member to submit the form to their local home plan; or
  • The provider can submit the questionnaire to the local plan in which they provided services.

Coordination of Benefits (COB) Questionnaire form

Preferred Provider Referral Form

This form is intended for submission by Preferred Providers within a tiered network product who are not part of the tiered network health system.

Participation and credentialing

 

The following forms are located in Availity Essentials Payer Spaces under the Resources tab:

  • Change of Tax ID
  • Provider Directory Maintenance
  • Update Provider Information
  • New Location / Business Relationship

Electronic Remit and EFT requests can be submitted through Availity Essentials under My Providers, then Enrollment Center.

Medicaid Expansion credentialing

Learn about Medicaid Expansion credentialing and the existing provider addendum process.

Practitioner recredentialing Application - Fillable PDF

If you are currently maintaining a credentialing application on CAQH ProView™ that you would like us to use, you can email your CAQH ID to us at prov.net@bcbsnd.com.

Practitioner Recredentialing Application

Pharmacy

Retail Pharmacy Forms

Coverage Exception
Pharmacy Coverage Exception Form – External Review
Patient Protection and Affordable Care Act (PPACA) Preventive Copay Waiver Form

If your benefit plan is subject to PPACA preventive services, you may request a Copay Waiver for a product within a preventive service class that is not a designated preventive service product.

Precertification

Request authorizations directly in Availity Essentials:

Inpatient Authorization Request
Outpatient Authorization Request

Repetitive Transcranial Magnetic Stimulation (rTMS) Authorization Request
Peer Support Services Form
ABA Form - For FEP use only

As of September 1st, 2024, for participatiing providers faxes will only be accepted when the below applies:

  • Provider received an error in Availity and Availity ticket number is referenced on the fax cover sheet.
  • When Availity Essentials or Predictal has downtime, BCBSND will notifty providers if this occurs and to utilize a fax option if necessary.

Reimbursement

Provider Chargemaster Update Notification Form

Please complete this form indicating the adjustment rates that have been approved or are planned for the facility noted.