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.
Participation and credentialing
The following forms are located in Availity Essentials Payer Spaces under the Resources tab:
Electronic Remit and EFT requests can be submitted through Availity Essentials under My Providers, then Enrollment Center.
Medicaid Expansion credentialing
Facility/Organization Recredentialing applications - Fillable PDF's
Ambulance Recredentialing Application
Behavioral Health – Institutional Provider Recredentialing Application
Durable Medical Equipment Recredentialing Application
Healthcare Organization Recredentialing
Home Infusion Recredentialing Application
Medication-Assisted Treatment Facility Recredentialing Application
Optical Supplier Recredentialing Application
Public Health Unit Recredentialing Application
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 email@example.com.
Medicaid Expansion ER Admission Notification
We are required by the state of North Dakota to contact all Medicaid Members within 72 hours of being discharged from the Emergency Room (ER). To assist us, please submit the attached form as soon as possible after discharge.
Note: if the Medicaid Member is admitted to the hospital, there is no need to submit a form.
Medicaid Expansion Crisis Utilization
Providers delivering crisis services for Medicaid Expansion members must notify BCBSND through the Medicaid Expansion Crisis Utilization form. Services include:
Medicaid Expansion Non‑Emergency Transportation, Meals, and Lodging Billing form
Retail Pharmacy Forms
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.
Not able to access Availity Essentials? Download the pdf form:
This form is to accompany the appropriate authorization request
ABA Service for Autism Spectrum Disorder Request Form