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TENNESSEE BLUE CROSS BLUE SHIELD DENTAL …

220 Burnham Street South Windsor, CT 06074. Vox 888-255-7293 Fax 860-289-0055. TENNESSEE blue CROSS blue SHIELD . DENTAL electronic CLAIMS ENROLLMENT REGISTRATION. PAYER ID NUMBER CBTN1. If a provider does not have a TENNESSEE BCBS provider number the provider SPECIAL NOTES must first submit a paper claim to have one assigned. electronic Change Healthcare Provider Enrollment Form Please complete all requested information. REGISTRATIONS. electronic Billing Request Agreements Required Please complete all requested information. SEND REGISTRATION Change Healthcare 220 Burnham Street FORMS TO South Windsor, CT 06074. Attn: Provider Enrollment Or Fax to: 860-289-0055. ENROLLMENT Change Healthcare will notify the provider or their PMS vendor, as defined by the PMS vendor, when registration is complete.

220 Burnham Street South Windsor, CT 06074 Vox 888-255-7293 Fax 860-289-0055 Page 1 of 2 Updated 8/7/2012 TENNESSEE BLUE CROSS BLUE SHIELD . DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION

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Transcription of TENNESSEE BLUE CROSS BLUE SHIELD DENTAL …

1 220 Burnham Street South Windsor, CT 06074. Vox 888-255-7293 Fax 860-289-0055. TENNESSEE blue CROSS blue SHIELD . DENTAL electronic CLAIMS ENROLLMENT REGISTRATION. PAYER ID NUMBER CBTN1. If a provider does not have a TENNESSEE BCBS provider number the provider SPECIAL NOTES must first submit a paper claim to have one assigned. electronic Change Healthcare Provider Enrollment Form Please complete all requested information. REGISTRATIONS. electronic Billing Request Agreements Required Please complete all requested information. SEND REGISTRATION Change Healthcare 220 Burnham Street FORMS TO South Windsor, CT 06074. Attn: Provider Enrollment Or Fax to: 860-289-0055. ENROLLMENT Change Healthcare will notify the provider or their PMS vendor, as defined by the PMS vendor, when registration is complete.

2 CONFIRMATION. CHANGING electronic If the Provider currently submits claims through another Billing Agent other than Change Healthcare DENTAL each Provider BILLING AGENTS must re-enroll following the procedures listed above. CONTACT PHONE NUMBERS TENNESSEE BCBS Provider Enrollment 800-924-7141. Change Healthcare DENTAL 888-255-7293. Page 1 of 2. Updated 8/7/2012. 220 Burnham Street South Windsor, CT 06074. Vox 888-255-7293 Fax 860-289-0055. PROVIDER ENROLLMENT FORM. Insurance Carrier: TENNESSEE BCBS- payer IDs CBTN1. Print/Type the following: Provider/Organization Name: _____. Tax Identification or Social Security Number: _____. (Number that will be used to submit electronic claims). Software Vendor: _____. Group Legacy Number as assigned by the payer:_____. (if applicable).

3 Group Type 2 NPI: _____. (if applicable). Rendering Provider Information Name Legacy Number Required for all providers NPI Type 1. _____ _____ _____. _____ _____ _____. _____ _____ _____. _____ _____ _____. Address: _____. City, State, Zip Code: _____. Office Contact Name: _____. Telephone Number: _____ Fax Number: _____. Date: _____. Page 2 of 2. Updated 8/7/2012.


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