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In the section below, identify the provider codes for Blue Cross Blue Shield of Michigan, Blue Care Network, and Medicare that you wish to access claim information. Also identify all payers you wish to submit electronic claims by supplying the appropriate provider identifier. Remember BCBSM providers need to report the National Provider Identification Number (NPI).
(For BCBSM use only) Secured Access ID# COMMENTS:
If you are only requesting additional Provider Secured Services IDs, enter the User ID from this office you would like to have cloned with the same provider codes.
Contact Person's Telephone and Extension
Email Address to receive assigned Provider Secured Services ID(s)
Provider Specialty
Professional Provider Secured Access Application
Street Address and Suite Number (address where users are located) Contact Person
City State Zip Code
Are Your Claims Submitted Electronically ? Yes NoTax ID:
Provider or Group Name
Provider NPI Number
Do you formally participate with BCBSM in accepting payments? Yes No Does your office have access to Provider Secured Services? Yes No If yes, list your current Provider Secured Services ID
© 1996-2013 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
TO OBTAIN SECURED ACCESS USER IDs, YOU MUST COMPLETE PAGE 2 OF THIS FORM.
TO VIEW AN EXAMPLE OF A SPECIFIC REQUIRED CODE, PLACE THE MOUSE POINTER IN THE CENTER OF THE INPUT FIELD BELOW.
Medicare Provider Codes
WF 10905 JAN 13
Internet Claims Submission Office/Practice Name (where users are located)
( )
Mail or Fax application to: Blue Cross Blue Shield of Michigan 53200 Grand River Mail Code L830 New Hudson, MI 48165 Fax #: 1-800-495-0812
If you are cloning an ID, stop here and go to page 2 of this application.
Michigan Medicaid NPI
USERS CANNOT TAKE THEIR ASSIGNED IDs TO OTHER PRACTICES/LOCATIONS
Office/Practice Name
Provider Secured Services ID
If no, you must complete the "Use and Protection Agreement"
Select Applicable Line of Business for the assigned 10-digit NPI Number BCN BCBSM BCBSMBCN BCN BCN BCBSMBCBSM
Provider's Name
Provider's Name
Assigned 10-digit NPI Number
Assigned 10-digit NPI Number
Requesting e-Referral Access (BCN-Affiliated Providers Only)Note-All listed providers are automatically added to the existing practice/group and are immediately available for e-referral
For offices that currently have access to e-referral and are requesting access for additional users, please provide a Provider Secured Services ID for verification purposes
IF YOU HAVE ANY QUSTIONS, PLEASE CALL 877 258 3932
For BCBSM Use Only
BCN PCP Claims
Summary
Claims Tracking
& EFT
User's Telephone # and Extension
Practice Name (Provider Name)
Professional Provider Secured Access ApplicationTO OBTAIN SECURED ACCESS USER IDs, YOU MUST COMPLETE THIS FORM.
Name (Type in full legal name for each user)
EXAMPLE: John B Doe
EXAMPLE: Jane Smith
248-222-1111
AUTHORIZATION FOR USE AND ACCESSI hereby state the information provided on this application is correct and the provider codes listed pertain to my practice only.
Provider Authorized Signature Date
Type or Print Name of the Authorized Signer Signer's Title
248-222-1112 ext. 231
Internet Claims Trans
TYPE THE NAME(S) AND PHONE NUMBER(S) OF THE INDIVIDUAL(S) REQUIRING PROVIDER SECURED ACCESS CHECK ALL FEATURES YOU ARE REQUESTING FOR EACH USER
All individuals using Provider Secured Services must be included below to receive their own user ID. Provider Secured Services user IDs may not be shared among the office staff. Note: All users will automatically receive access to web-DENIS and web-DENIS eligibility.
By signing above, I represent and warrant that I have been granted full legal authority, by corporate resolution, appropriate delegated signature authority, or as permitted by a signature authorization policy, to enter into and bind the provider and/or provider group to contracts and agreements and, intending to be legally bound, have executed this agreement on the date listed above. © 1996-2013 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
NOTE: If additional space is needed, attach a separate listing of the names and telephone numbers for each user requiring secured access.
XX
X X
Do not use a signature stamp on the line above
IF YOU HAVE ANY QUESTIONS, PLEASE CALL 1-877-258-3932
e-referral Access
(BCN Only)
X
Professional Claims
Correction (PCC)
X
X