Provider Enrollment and Change Process Required Document Checklist
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1 Provider Enrollment and Change Process Required Document Checklist Provider Classification To avoid processing delays gather these items before you get started. If applying to network, complete the application signature document for each network. Ambulance, Air and/or Ground New Allied Provider Enrollment -or- Allied Provider Change Michigan license as a Life Support Agency (ground and air) Federal Aviation Association (FAA) 135 Certificate (air only) Ambulatory Surgical Facility New Allied Provider Enrollment -or- Allied Provider Change Anesthesia Assistant New Allied Provider Enrollment -or- Allied Provider Change accept W-9-s) Audiologist New Allied Provider Enrollment -or- Allied Provider Change number accept W-9-s) Board Certified Behavior Analyst New Mental Health Practitioner Enrollment -or- Mental Health Behavior Analyst Board Certification Certified Nurse Midwife New Allied Practitioner Enrollment -or- Allied Provider Change number WP SEP 2014 Page 1 of 8
2 Certification from the American College of Certified Nurse Midwives (ACCNM) with effective an expiration dates identifying TIN and associated payee name (BCB) For CNMs performing deliveries, the following are also required: - Written confirmation of established privileges with hospital(s) and/or has hospital-affiliated birthing centers Written confirmation of an established, interdependent relationship for medical consultation/collaboration or referral to an OB/GYN - refer to Addendum B, Qualification Standards in CNM Provider Participation Agreement Certified Nurse Practitioner New Allied Practitioner Enrollment for -or- Allied Practitioner Change number Certification from one of the following national entities with effective and expiration dates: - American Nurse Credentialing Center (ANCC) - National Certification Corporation for the Obstetric/Gynecology and Neonatal Specialties - National Certification Board of Pediatric Nurse Practitioners and Nurses - Nurse Practitioner Program of the United States Department of Health and Human Services - The Oncology Nursing Certification Program CAQH Number (if available) Certified Registered Nurse Anesthetist New Allied Practitioner Enrollment -or- Allied Provider Change National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) or, Certification from the Council on Certification of Nurse Anesthetists or, Certification from the Council on Recertification of Nurse Anesthetists Chiropractor New Practitioner Enrollment -or- Allied practitioner Change Page 2 of 8
3 Clinical Independent Laboratory New Allied Provider Enrollment -or- Allied Provider Change Clinical Laboratory Improvement Amendments (CLIA) Certificate Certified Nurse Specialist New Mental Health Practitioner Enrollment -or- Mental Health Dentist New Allied Practitioner Enrollment -or- Allied Practitioner Change Doctor of Medicine New Practitioner Enrollment -or- Doctor of Osteopathy New Practitioner Enrollment -or- Durable Medical Equipment Supplier New Allied Provider Enrollment -or- Allied Provider Change Page 3 of 8
4 Freestanding Radiology Center identifying TIN and associated payee name (BCBSM.BCN does not New Allied Provider Enrollment -or- Allied Provider Change Liability/Malpractice Insurance verification (for BCN, BCNA BCC networks) Accreditation Certificate from one of the following: American College of Radiology or, Intersocietal Accreditation Commission or, The Joint Commission Certificate of Need for PET, MRI and Megavoltage Radiation Therapy as an independent diagnostic testing facility or, a Medicare Approval Letter as a radiology physician practice matching primary practice location Primary practice location in Michigan Identified owner of Facility Staff Roster (complete list) with Medical Director Hearing Aid Dealer New Allied Practitioner Enrollment -or- Allied Practitioner Change Independent Diagnostic Testing Facility Independent Occupational Therapist New Allied Provider Enrollment -or- Allied Provider Change New Practitioner Enrollment -or- Page 4 of 8
5 Independent Physical Therapist New Practitioner Enrollment -or- Independent Speech Language Pathologist New Allied Practitioner Enrollment -or- Allied Practitioner Change, if available Certificate of Clinical Competence from the American Speech-Language Hearing Association Page 5 of 8
6 Licensed Master of Social Worker New Mental Health Practitioner Enrollment -or- Mental Health Opthalmologist New Practitioner Enrollment -or- Optician/Optical Supplier New Allied Provider Enrollment -or- Allied Provider Change Optometrist New Allied Practitioner -or- Allied Oral Surgeon (board certified medical-surgical only) New Practitioner Enrollment -or- Council for Affordable Healthcare Quality (CAQH) number (if available) Physician Assistant New Allied Practitioner Enrollment -or- Allied Practitioner BCBSM Physician Assistant Supervising Physician/Employer Certification Physiological Laboratory New Allied Provider Enrollment -or- Allied Provider Change Page 6 of 8
7 Podiatrist New Practitioner Enrollment -or- Professional Group Practice New Group Enrollment -or- Group Change Prosthetic and Orthotic Suppliers New Allied Provider Enrollment -or- Allied Provider Change Type1 National Provider Identifier (for individually certified suppliers) (for organizationally certified suppliers) (for individually certified suppliers) Valid certification for Prosthetic and Orthotic Checklist: Accreditation Commission for Health Care INC American Board of Certification in Orthotics & Prosthetics Board of Certification/Accreditation International Commission of Accreditation of Rehabilitation Facilities Community Health Accreditation Program Health Care Quality Association on Accreditation National Association of Boards of Pharmacy The Compliance Team, Inc. The Joint Commission The National Board of Accreditation for Orthotic Psychiatrist New Mental Health Practitioner Enrollment -or- Mental Health Psychologist (fully licensed) New Mental Health Practitioner Enrollment -or- Mental Health Page 7 of 8
8 Urgent Care Center New Allied Provider Enrollment -or- Allied Provider Change Vaccine Pharmacy New Provider Enrollment -or- Provider Change Copy of BCBSM Pharmacy Network Administration Approval Letter (contact to obtain approval letter) Page 8 of 8
Provider Enrollment and Change Process Required Document Checklist
Provider Enrollment and Change Process Required Document Checklist Provider Classification To avoid processing delays gather these items before you get started. If applying to network, complete the application
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