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For enrolled provider that have not been inactive or cancelled from participating status for six months or more.
Blue Cross and Blue Shield of Alabama enrolls and credentials all individual providers as well as ancillary and facility providers. Here are the forms/documents to add locations and make changes to information and other requests.
An application, from the Enrollment section, is needed for any provider in the following situations:
- New providers practicing within the State of Alabama and that need to be enrolled for claims processing
- Inactive or canceled providers (six months or more) that no longer have network status (use the UPA from the Enrollment section)
- New providers joining an existing tax identification number
Note: Providers outside of Alabama must be participating with their local Blue Plan for consideration for participation with Blue Cross and Blue Shield of Alabama.
Existing providers who are:
- Adding a new location, or
- Joining an existing tax identification number, or
- Changing the tax identifcation number for an existing practice.
Follow the steps below:
Step 1 - Required Documents for All Providers/Specialties
There are several required documents that you must submit for enrollment. Print this Practitioner Checklist or Facility/Business Checklist to track your progress throughout enrollment and ensure that all necessary documents/forms are submitted. Some of the required forms are provided in step 2.
Step 2 - Provider Enrollment Application/Supporting Documents
Click on the appropriate specialty from the list below to view and print the application and list of supporting documents necessary for enrollment. By utilizing the proper application and returning the correct supporting documents, you can significantly speed up the enrollment process. Submit all current supporting documentation in a legible format.
Applications/Supporting Documentation Requirements
- Ambulatory Surgery Center (ASC)
- Ancillary Provider (Not located in Alabama)
- Anesthesiologist Assistants
- Audiologists/Hearing Instrument Specialists
- Certified Registered Nurse Anesthetist (CRNA)
- Dentist (General)
- Healthcare Facility Application
- Independent Laboratory
- Nurse Midwife
- Nurse Practitioner
- Occupational Therapist
- Oral Surgeon
- Physical Therapist
- Physician Assistant
- Physician Laboratory
- Physicians (MD or DO) or you can print an application to Add a new Provider location
- Podiatrist or you can print an application to Add a new Provider location
- Speech Language Pathologist
- Ground Ambulance, Optical Dispensary, Home Health, Hospice, DME or other Suppliers
- Not Listed Above
Step 3 - Express Your Network Interest
Complete the Practitoner Network Interest Form or the Facility Business Network Interest Form that is included with the application for your specialty. It is required for all new applications and expresses your interest in network participation. After the enrollment process is complete, a provider will be reviewed and may be invited to participate in a network if all criteria are met.
- Enrollment is not the same as joining a Blue Cross Provider Network.
- Enrollment and expressed interest in network participation are not a guarantee of acceptance as a participant in a network.
Step 4 - Enroll in Electronic Funds Transfer (EFT) - Required
Register Online for Direct Deposit/EFT or complete the EFT Authorization Agreement that is included with your application. EFT provides an easy and efficient way to ensure your Blue Cross and Blue Shield of Alabama payments are deposited directly into your bank account. It's secure, confidential and convenient, and there is no charge to you for this service.
|Application Document Package - Includes all forms that are required for new and existing providers.||
Interested in Joining a Network
Update Office Address
Update Payee/Remit Address*
Update Tax Address*
Update Telephone Numbers
Update Provider or Office Email
Changes in Organizational/Payee NPI*
Authorization to Contact facilities for verification
Substitute W9 Documentation
Set up Direct Deposit of Remittances
PRP New Physician Form
Add a new physician to the the Preferred Radiology Network
|Preferred Radiology Program New Physician Form|