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.
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:
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:
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 firstname.lastname@example.org.
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: