Provider forms and documents

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 Form (Please note: The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.)

Authorized referral

Please note: Submit through the Availity portal on the Referrals page

Comprehensive orthodontic treatment plan

Participation and credentialing

 

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

  • Accepting New Patients
  • Application to Become a Participating Provider
  • Change of Tax ID
  • Provider Directory Maintenance
  • Update Provider Information
  • New Location / Business Relationship

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

Recredentialing Applications

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

  • Ambulance
  • Behavioral Health - Institutional Provider
  • Durable Medical Equipment
  • Healthcare Organization
  • Home Infusion
  • Medication-Assisted Treatment Facility
  • Optical Supplier
  • Practitioner
  • Public Health Unit

Not registered yet?

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