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


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 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 Provider Referral Form

DakotaBlue | Altru Provider Referral Form

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

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

Practitioner Recredentialing Application

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 ER Admission Notification

Medicaid Expansion Crisis Utilization

Providers delivering crisis services for Medicaid Expansion members must notify BCBSND through the Medicaid Expansion Crisis Utilization form. Services include:

  • Resources/Education
  • Support/Active listening
  • Crisis Intervention
  • Social Detox
  • 911/Police
  • Emergency Room
  • Mobile Crisis Team
  • Community Chaplin

Medicaid Expansion Crisis Utilization Form

Medicaid Expansion Non‑Emergency Transportation, Meals, and Lodging Billing form


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.


Provider Chargemaster Update Notification Form

Please complete this form indicating the adjustment rates that have been approved or are planned for the facility noted.