Instructions for document submission - bcbsm.com

1 WF 10582 MAY 22 Page 1 of 12 Instructions for fax cover sheetWe cannot accept handwritten forms. Do not hand write anywhere on the forms, otherwise processing will be ensure forms are processed timely, please adhere to the following Instructions : For individual practitioners From (Insert name of contact person) Date (MM/DD/YYYY) Type 1 NPI (National provider Identifier) 10 digit state license number When adding an individual to an existing group, be sure to fax a group change form For allied providers From (Insert name of contact person) Date (MM/DD/YYYY) Type 2 NPI (National provider Identifier) Tax identification number For professional group practices and facilities From (Insert name of contact person) Date (MM/DD/YYYY) Type 2 NPI (National provider Identifier) Tax identification numberInstructions for document submission1.

2 Fax cover sheet must be the first page of your form Fax the registration form and attachments ( , signature documents) to 1-866-900-0250. Be sure to fax the registration information separately for each provider . (For example: If you register two or more providers, you must send a fax for each provider . They cannot be bundled into one fax transmission.).Questions? Call 1-800-822-2761 WF 10582 MAY 22 Page 2 of 12 NEW GROUP ENROLLMENT FORMFAX COVER SHEET FOR DOCUMENTSIMPORTANT: Attach this page to the top of your document to avoid processing To:866-900-0250 provider EnrollmentFrom:Date:Form Number:10582 Type 2 NPI:Tax Identification Number:Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. WF 10582 MAY 22 Page 3 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 1: Demographic Data *denotes a required field*Group name*Group specialty*County where your primary address is located*Website*EIN/Tax ID number*EIN/Tax name as indicated on Internal Revenue Service document *Tax exempt Yes NoAre you a Retail-based Health Clinic?

3 Yes NoAre you a Community Mental Health Center Yes NoAre you a Federally Qualified Health Center? Yes NoAre you an Indian Health Service provider ? If yes, are you limited to tribal members only? Yes No Yes NoAre you a Student Health Services provider ? Yes NoAre you considered an Essential Community provider under the Affordable Care Act?See Section 7 for additional information on participation? Yes NoAre you applying as an Urgent Care Center? Yes NoIf you are an incorporated individual billing with your Type 2 NPI, you must also complete a New Practitioner Enrollment form to register your Type 1 NPI for billing 2: Requested networksRequested effective date - The actual effective date will be determined based on the provisions in the applicable Participation/Affiliation agreements.

4 Your requested effective date cannot precede the date the group was formed as a bona fide legal entity. Important: Along with the application, it is necessary to complete and submit the signature document appropriate for your provider type. For each network you wish to participate in, be sure to place a check mark by the appropriate affiliation agreement, sign the signature document , and submit it along with this and BCN do not permit retroactive effective dates in managed care networks you are apply to: bcbsm networksRequested networksTraditional Participating Nonparticipating Requested effective date:Vision Participating Nonparticipating Requested effective date:Hearing Participating Nonparticipating Requested effective date:BCN networksRequested networksBCN CommercialBCN AdvantageSM HMO WF 10582 MAY 22 Page 4 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 3.

5 Address data *denotes a required fieldPrimary office address (Must be an address where health care services are rendered and may be published in bcbsm /BCN provider directories)*Street address*City*StateZIP codePrimary telephone number must be a phone number patients can call to make an appointment*Primary telephone numberFax numberPayment addressStreet AddressCityStateZip CodeMailing addressStreet AddressCityStateZip CodeContact information (Please provide the name and contact information of a person who can answer questions about information in this application)*First nameLast name*Telephone numberextensionFax numberE-mail addressPreferred method of contact? Email US MailMedical Records Request (MRR)Street AddressCityStateZip CodeContact Name - FirstMiddleLastTelephoneFaxEmail WF 10582 MAY 22 Page 5 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 3: Address data (continued)Additional address - Accessibility*Handicap accessibility: Yes No*Accessible by bus: Yes No*Primary address - Office HoursOffice HoursMondayTuesdayWednesdayThursdayFrida ySaturdaySundayOpen TimeClose TimeDoes your group provide in-home visits?

6 Yes NoSection 4: ServicesTelehealth ServicesTelehealth - Audio/Visual Telehealth - Telephone OnlyServices: Select the services your group performsRadiology Services:Bone DensityMobile UnitOncologyCT ScanMRIPET ScanDiagnostic TestingMRI of BreastRead-onlyFluoroscopyMRI - OpenRoutine XrayMammographyNuclear MedicineUltrasoundSleep Testing Services:Home Testing If yes, are you accredited by the American Academy of Sleep Medicine?In-Center Sleep Testing If yes, are you accredited by the American Academy of Sleep Medicine?Yes No Yes NoYes No Yes NoIf Yes is selected, attach a copy of your AASM accreditation certificate. If it is not attached, your request may be Services:Select the following telehealth services you provide:Telehealth Offered-audio and visualTelehealth Originating SiteReal-time online visit/e-visit WF 10582 MAY 22 Page 6 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 4: Services (continued)Behavioral Health Services Select the following Telehealth services you provide:Telehealth ServicesTelehealth - Audio/Visual Telehealth - Telephone OnlySelect Age Ranges Treated: 0-12 (Child) 3-17 (Adolescent) 18-64 (Adult) 65+ (Geriatric) Other: Check Counseling Services ProvidedMental Health Outpatient ServicesSubstance Use Outpatient ServicesSAMHSA certified Opioid Treatment Program (OTP) - select applicable programs below.

7 Are you currently accepting new patients for SAMHSA Certified Opioid Treatment Program? Yes No WF 10582 MAY 22 Page 7 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 4: Services (continued)In an effort to assist us match patient need to available providers, please indicate your facility s special areas of interest below. Select no more than ten total treatment specialties and treatment modalities. We will use this information in directing members for specific services. Our expectation is that your practice is open and accepting new cases if you indicate specialties selecting the below specialties or modalities, you are attesting that you or your staff have received specialized education, training, and supervision in that Treatment SpecialtiesAppropriate Treatment ModalitiesADD / ADHDAddADOS Testing (trained / qualified) for AutismAddAnxiety, Phobias and Related DisordersAddAdult Intensive Services (AIS)AddAutismAddApplied Behavior Analysis (ABA) for AutismAddBereavement / Grief / LossAddBariatric EvaluationsAddDisorders of Childhood & AdolescenceAddBrief Dynamic TherapyAddDissociative DisordersAddChildren s Intensive Services (CIS)AddEating and Feeding DisordersAddCognitive Behavioral Therapy (CBT)AddGambling DisorderAddDialectical Behavioral Therapy (DBT)

8 AddGaming (compulsive)AddElectroconvulsive Therapy (ECT)AddGender / Transgender IdentificationAddExposure Response Prevention (ERP) TherapyAddGeriatric / Older Adult DisordersAddEye Movement Desensitization Reprocessing (EMDR)AddHIV / AIDSAddInterpersonal TherapyAddLGBTQ+AddMedication Assisted Treatment (MAT) for Opioid Use Suboxone/BuprenorphineAddMood DisordersAddObsessive Compulsive and Related DisordersAddMedication Assisted Treatment (MAT) for Opioid Use Vivitrol/NaltrexoneAddOpioid Use DisordersAddPain ManagementAddNAVIGATEAddPersonality DisordersAddNeurofeedback (for ADHD only)AddPregnancy ChallengesAddNeuropsychological TestingAddPsychotic DisorderAddPsychological TestingAddPTSD / Trauma DisordersAddTranscranial Magnetic Stimulation (TMS)AddSelective MutismAddSexual AddictionAddSexual DysfunctionAddSubstance Use DisordersAddTraumatic Brain InjuryAdd WF 10582 MAY 22 Page 8 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 5: Additional practice locations(Must be an address where health care services are rendered and may be published in bcbsm and BCN provider directories)If you have additional locations, please list and attach separately.

9 #1 Street AddressCityStateZIP CodeTelephone NumberFax NumberAdditional address - Accessibility*Handicap accessibility: Yes No*Accessible by bus: Yes NoOffice HoursMondayTuesdayWednesdayThursdayFrida ySaturdaySundayOpen TimeClose Time#2 Street AddressCityStateZIP CodeTelephone NumberFax NumberAdditional address - Accessibility*Handicap accessibility: Yes No*Accessible by bus: Yes NoOffice HoursMondayTuesdayWednesdayThursdayFrida ySaturdaySundayOpen TimeClose Time#3 Street AddressCityStateZIP CodeTelephone NumberFax NumberAdditional address - Accessibility*Handicap accessibility: Yes No*Accessible by bus: Yes NoOffice HoursMondayTuesdayWednesdayThursdayFrida ySaturdaySundayOpen TimeClose Time WF 10582 MAY 22 Page 9 of 12 NEW GROUP ENROLLMENT FORMTax Identification NumberType 2 National provider IdentifierSection 6: Add group members (continued)If you have additional practitioners, please duplicate this page for each practitioner and respond to the questions as (First Name , Last Name)DegreeNPIList practice address # s from Section 5, where this provider practices ( , Primary, 1, 2, 3).

10 Also check the appropriate box about each individual s practice Location: Can a patient make an appointment to see this practitioner on a regular basis at this location?Does this practitioner cover or fill-in for colleagues within the same medical group on a needed basis?Does this practitioner read tests or provide other services but does not see patients at this location?Yes NoYes NoYes NoOther: Location #2 Can a patient make an appointment to see this practitioner on a regular basis at this location?Does this practitioner cover or fill-in for colleagues within the same medical group on a needed basis?Does this practitioner read tests or provide other services but does not see patients at this location?Yes NoYes NoYes NoOther: Location #3 Can a patient make an appointment to see this practitioner on a regular basis at this location?