CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Provider forms and documents

Download Provider Manual

Experiencing Processing Issues? View system issue status grid

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.)

Comprehensive orthodontic treatment plan

Authorized referral

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

Participation and credentialing

 

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

Please complete if you received a letter requesting updates.
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

Secure Area Assurance – Medical Records Fax Requests

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