Member Services Representatives unavailable May 27

Our member services representatives will not be available Monday, May 27, due to the holiday.

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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 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

DakotaBlue | Altru and DakotaBlue | Trinity

Provider Referral Form

DakotaBlue | Altru and DakotaBlue | Trinity

Provider Referral Form

This form is to be used to submit a referral by DakotaBlue | Altru and DakotaBlue | Trinity Network Preferred Providers that are not part of the Altru or Trinity 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.

Medicaid Expansion forms

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.

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.