Blue Cross and Blue Shield of Alabama : Add Provider Location

Add New Provider Location

Adding Records
Adobe Acrobat Reader
Blank Application
Blue Cross Specific Forms
Changing Records
Contact Information
Covering Physicians

Current Hospital Admitting Privileges
Deleting Records
Editing your Application
Final Review
Modifying Records
Print Final Application

Practice Information
Practitioner Information
Provider Authorization
Required Fields
Saving your Application
State Medical License
Submit the Application

How to Add A New Record

To add a new record to any section, simply enter the required data in the fields on the screen. Then select the "Add" button at the bottom of the page. The record will then be edited. If there are no problems, the record will be added and then display in the data list. If there is an error, the error message will display at the top of the page. Correct the error and then select "Add" again.

Adobe Acrobat Reader

Make sure that you have the free Acrobat Reader® software installed on your computer prior to printing the application. The software can be downloaded for free from the Adobe web site.

Editing your Application

You do not have to complete the application in one sitting. Instead, you may work on the application over an extended time period. You also do not have to complete the application in any particular order.

Saving your Application

Your application is saved each time you update a record within your application. However, if you use the links on the left navigation bar or select the "Next Section" button without first updating any changes, you will lose those changes.

How to Delete a Record

To delete an existing record on your application, select the "Delete" button that displays to the right of your data. You will be asked to confirm that you want to delete the record.

Required Fields

All fields that have a red asterisk (*) next to the field name are required. No application can be submitted or printed until all required fields are completed. However, you may save a record without entering all required fields. Minimal data is required in order to save a record. The required fields must all be entered prior to printing a final copy or submitting an electronic application to Blue Cross.

How to Change a Record

Any existing record may be changed by selecting the “Modify” button that displays to the right of the data. When you select “Modify”, the data displays at the bottom of the page. You can then make any changes. After you change the data, you must select the “Update” at the bottom of your screen. This will save all changes. If you do not select “Update”, all changes will be lost.

If you select "Modify" and then you do not want to change the record, simply select the "Clear" link that is located directly above to the right of the record.

Printing a Final Copy of the Application

You can print a final copy of your application only after you have completed the Final Review. The “Print Application” is located on the Final Review page. Make sure that you have the free Acrobat Reader® software installed on your computer prior to printing the application. The software can be downloaded from the Adobe web site. After the application is printed, it can be copied and mailed to any hospital or insurance company. You do not need to mail a copy to Blue Cross and Blue Shield of Alabama if you used the “Submit to Blue Cross” button on the Final Review page.

Final Review

All applications go through a final review before they can be submitted to Blue Cross and Blue Shield of Alabama or printed. The final review verifies that all required data is complete. If errors exist on the application, the errors will display with a red “Incomplete” message. Please select the data that is in error and correct. Then return to the Final Review page and re-run the final validation. This process must be repeated until there are no more errors.

Submit the Application

After the application has been completed, it may be submitted to Blue Cross and Blue Shield electronically. After the Final Review has been completed, select the "Submit to Blue Cross" button on the top left of the page. This will notify Blue Cross that you have submitted your application. The application may be printed using the Print Final Application button on the top right of the page. This copy may be sent to any hospital or health plan in Alabama that you are applying to. If you submit your application to Blue Cross using the web site, you do not have to mail a paper copy to Blue Cross.

Practitioner Information

On this page, you should enter basic information about the practitioner. Any fields that have an * next to the field name are required before you can submit the final application or print a final copy.

E-mail Address - This should be a valid e-mail address for the practitioner.
ECFMG Number - If you completed your medical school or medical training in a foreign country, you must provide your ECFMG number.
Degree Type - If your degree is not listed, you must specify your degree.
Alien Registration Number - If you are not a US Citizen then you must provide your alien registration number.

Practice

On this page, you should enter information about your practices. You should list each practice individually. At least one practice is required. Any fields that have an * next to the field name are required before you can submit the final application or print a final copy.

Tax ID - This should be entered without a hyphen.
DBA - Doing Business As
Appointment Telephone Number - This is required of all physicians unless your specialty does not take appointments. The excluded specialties are This is required of all physicians unless your specialty does not take appointments. The excluded specialties are Anesthesiology, Emergency Medicine, Nuclear Medicine, Osteopathic Manipulative Therapy, Pathology and Radiology.
Office Hours - These are required of all physicians unless your specialty does not have an office. The excluded specialties are Anesthesiology, Emergency Medicine, Nuclear Medicine, Osteopathic Manipulative Therapy, Pathology and Radiology.
Are you accepting new patients? - You may only answer Not Applicable to this question if your specialty is Anesthesiology, Emergency Medicine, Nuclear Medicine, Osteopathic Manipulative Therapy, Pathology or Radiology.
Medicaid Number - If you do not have an Alabama Medicaid Number, because it has been applied for but not received, just leave the field blank.
Billing Address - If your Billing Address is the same as your Office Practice Address, then you can select the checkbox and the address will be automatically copied for you. However, it can be overridden if necessary.

Covering Physicians

If you have physicians that cover for you, you should enter their names here. Your covering physicians should agree to the same fees and follow the same administrative procedures. Covering Physicians are not required. Any fields that have an * next to the field name are required before you can submit the final application or print a final copy.

First Name - The first name of your covering physician is required to save a record.
Last Name - The last name of your covering physician is required to save a record.

Specialty - Your covering physician's specialty is required to save a record. If the specialty is not listed in the drop down box, choose Select Specialty from the drop down and enter a specialty in the next field.

State Medical License

Your State Medical License information should be entered on this page. You must hold a valid Alabama Medical License or have applied for an Alabama Medical License, before this application can be completed. Any fields that have an * next to the field name are required before you can submit the final application or print a final copy.

If you have applied for a State license but not yet received one, the only field required is to select this option. If you currently hold a valid State license, all fields on this page are required.

Current Hospital Admitting Privileges

Please list all hospitals that you are currently have admitting privileges with. You should also include any hospitals that you have applied to. Any fields that have an * next to the field name are required before you can submit the final application or print a final copy.

Staff Category - Please select your staff category from this list. If there is not a description that fits your category, select the Select Category option from the list, and enter your staff category in the following field.
If your Staff Category is Applied/Pending, you must list your application date.
Admit Patients - If you admit patients to this hospital, please list the percent of admissions from 0-100 that you admit. If you do not admit patients because your specialty does not require this, then you may select this option. If you do not admit patients for any other reason, you must provide an explanation as to why and enter the name of the physician who will admit on your behalf.

Provider Authorization

You should carefully review the provider authorization page. You must either agree or disagree to this information. You must agree to this attestation in order to submit your application to Blue Cross or to print a final copy to send to any other hospital or insurer. If you do not agree to this attestation, you will not be allowed to print a final copy of this application or electronically submit your application to Blue Cross.

Blue Cross Specific Forms

You do not need to send the completed form to Blue Cross as long as you choose the "Submit to Blue Cross" button. However, there are some additional forms that Blue Cross needs to be completed and mailed or faxed.

1) Copy of IRS documentation (i.e. Letter 147T or 147C, Federal Deposit Coupon, Form 941, ETPS, or Letter CP575)
2) If you want to be a Preferred Radiologist and you are certified, you must send a copy of your MRI, PET and CT Certificates.
3) Copy of your State Medical License or Certificate

For your convenience, the following documents may be viewed
and/or printed by clicking on this PDF link:

Blue Cross Forms

4) A Tax Payer Identification Number Request for each Tax Number (Page 2)
5) A Hospital Information Release for each hospital that you are currently affiliated with. (Page 3)

All required documentation should be mailed to:

Blue Cross and Blue Shield of Alabama
Attention: Provider Enrollment and Credentialing
P.O. Box 362142
Birmingham, Alabama 35236-2142

The required information may also be faxed to (205)220-9545.

Once the requested information has been received, Blue Cross can
complete the processing of your application. You should hear
from us within ten days. Failure to send the required information
may delay the processing of your application. Please include your
Application Control Number on all correspondence. Additional
questions about your Blue Cross application can be directed
to (205)220-6765.

Please write your Application Control Number on the top of all correspondence.

Contact Information

This person will be contacted if there are any questions about the application.

Blank Application

You may print a copy of a blank application and mail or fax in the completed application. Click here to print a blank application.

This requires that you have the free Adobe Acrobat Reader installed on your computer. Click here for help on installing the Adobe software.