Ancillary Network Application Package
The purpose of collecting this information is to determine the eligibility of individuals and organizations to enroll in the Ancillary Network programs as providers/suppliers of goods and services to Blue Cross and Blue Shield of Alabama members and to assist in the administration of the Blue Cross and Blue Shield of Alabama Networks.
Authorization for Disclosure of Mental Health Clinical Information
This authorization will permit Physicians providing mental health services to Blue Cross and Blue Shield of Alabama Members to disclose your mental health clinical information that you describe below (”Mental Health Clinical Information”) to Blue Cross and Blue Shield of Alabama and its business associate(s) on behalf of your Health Plan and for the purpose that you describe below. This authorization is not required by Federal Law or your Group Health Plan, but may be utilized by Physicians in their practice.
Billing for Noncovered Services
As noted in section 4.5 of the Preferred Medical Doctor (PMD) contract, the physician is responsible for notifying the patient of noncovered services or those services not medically necessary for the treatment of his/her condition.
Before performing these services, you should obtain the patient’s signature on a written statement of noncovered services. This document should explain to the patient which services they will be responsible for and the amount of the charge.
ERA (835) Enrollment Form and Instructions
This should be completed by vendors, billing services and clearinghouses for each new payee wishing to receive electronic remittance files. Existing Vendors, please fax completed forms to 205-733-7362, Attention: Enrollment, or email to EDIEnrollment@bcbsal.org.
Existing Provider Checklist
Use this form when you are adding a location.
Facility Business Network Interest Application Form
This form is required for all new applicants and any provider interested in being added to a network. New providers must also complete an enrollment application found at AlabamaBlue.com.
Federal Employee Program Request for Certification
FEP: Hospice Services prior to or within 5 days of start of care. * Benefit Verification: Please verify before submission of information *
Health Mangement Division Request for Certification
Hospice Services prior to or within 5 days of start of care. * Benefit Verification: Please verify before submission of information *
Home Health Services Request for Certification
For home health services, prior to start of care. *Please verify contract benefit information before submission of form.*
In-State Dental Provider Application Form
This is the application form for Alabama-based dental providers as well as those in contiguous counties.
New EDI Vendor Form
There are additional required enrollment forms you must submit for your clients before their access to our data is permitted. The required forms vary dependent on whether your client is new to EDI, an existing EDI submitter, and which transactions they request. If you are a new vendor, you can contact our EDI vendor testing mailbox at firstname.lastname@example.org for assistance in the new vendor process.
Out-of-State Ancillary Provider Form
This form is used to establish an out-of-state ancillary provider with Blue Cross and Blue Shield of Alabama and assign a provider number.
Patient Handouts Request Form
Use this form to request patient handouts on health and wellness topics such as diabetes, high blood pressure, diet and exercise.
Personal Choice Network Retro-Referral Form
If a referral was not completed due to PCP error, please enter the referral in your usual method and then fax this completed form explaining the circumstances to 1-800-303-8930 or 205-220-5763.
Practitioner Network Interest Application Form
This form is required for all new applicants and any provider interested in applying for network inclusion. New providers must also complete an enrollment application. Providers adding a new location must submit this form to have Par Status added to the new location.
Predetermination Request Cover Sheet
Please complete this form and attach as your cover sheet along with supporting documentation and clinical rationale for a predetermination review.
Preferred Radiology Provider Program New Physician Notification
The Preferred Radiology Provider (PRP) Program New Physician Notification form needs to be completed whenever a Preferred Medical Doctor (PMD) provides services at your location and needs to be considered for addition to the Preferred Radiology Network as an accredited MRI, MRA, CT, CTA or PET provider. The completed form will help Blue Cross and Blue Shield of Alabama identify all new physicians coming into this Network and will allow us to assure that each of these physicians receives all of the benefits of this Network.
Provider Change Notification Form
Accurate and complete information is important for providers and Blue Cross and Blue Shield of Alabama. Our provider file is used for remittance payments, Internal Revenue reporting, directories and publication mailings. To update your information in our provider records, complete this form, sign and mail or fax it to the address listed.
Referral Form for Indian Health Services
This form is only needed for services received outside of an Indian Health Clinic
and is intended to protect tribal members from potential cost-sharing.