Provider forms and documents

Download Provider Manual

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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

New location

Are you already a participating credentialed provider with BCBSND but want to provide services at another location? If so, please use the form below.

New Location / Business Relationship Form

Participation and credentialing

 

Accepting New Patients Update Form
Application to Become a Participating Provider
Submit Change of Tax ID
Provider Directory Maintenance Form
Update Provider Information

EFT Payment Information

To receive EFT transfers, you must be set up for electronic remits

Already receiving electronic remits? Continue to EFT Payment Information Form

Don't receive electronic remits? Sign up to receive 835 payment listings through Availity.

Pharmacy

Retail Pharmacy Forms

Coverage Exception
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