BlueCross BlueShield Texas Ancillary Provider ID Form
This document is the Ancillary Provider ID request form for BlueCross BlueShield of Texas. It is necessary for providers seeking to establish their identity for claims processing. Ensure all sections are accurately completed to facilitate timely processing.
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How do I fill this out?
To fill out this form, start by gathering all necessary information including your corporate name, address, and contact details. Make sure you understand your provider status and whether you're adding an affiliate location. Carefully review the form to ensure all sections are filled accurately and completely before submission.
How to fill out the BlueCross BlueShield Texas Ancillary Provider ID Form?
1
Gather all required information, including corporate name and address.
2
Determine if you are adding an affiliate location to a parent hospital.
3
Select your provider status (Provider Based or Not Provider Based).
4
Complete all sections of the form accurately.
5
Attach required documents before submitting the form.
Who needs the BlueCross BlueShield Texas Ancillary Provider ID Form?
1
Healthcare providers seeking to establish a provider ID.
2
Facilities wishing to credential with BlueCross BlueShield Texas.
3
Newly affiliated locations of established hospitals need to provide information.
4
Doctors and facilities needing to submit claims for Out-of-Network patients.
5
Corporate entities managing healthcare services who need proper identification.
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What are the instructions for submitting this form?
Submit the completed Ancillary Provider ID form by emailing it to TXFPS@bcbstx.com or faxing it to the Facility Provider Services department. For physical submissions, mail to the address listed in the form. Ensure to include all required attachments for a successful submission.
What are the important dates for this form in 2024 and 2025?
Important dates regarding the Ancillary Provider ID form for 2024 include submission deadlines for new applicants and periodic review dates for existing providers. Ensure your credentials are up-to-date as per the specified timelines to maintain active status. Failure to comply with deadlines may affect your service and claims processing.
What is the purpose of this form?
The purpose of the Ancillary Provider ID request form is to facilitate the registration of healthcare providers with BlueCross BlueShield of Texas. This form gathers essential information required to establish a provider ID vital for claims processing and credentialing. By completing this form, providers gain access to necessary network services and streamline their interactions with BlueCross BlueShield.
Tell me about this form and its components and fields line-by-line.
- 1. Corporate Name: The official name of the provider as registered.
- 2. Address: Physical address of the practice.
- 3. NPI: National Provider Identifier required for credentialing.
- 4. Tax ID: Federal tax identification number for the business.
- 5. Provider Status: Indicates whether the provider is 'Provider Based' or not.
- 6. Contact Information: Includes phone numbers and emails for communication.
- 7. Signature: Signature of the applicant affirming the accuracy of the information.
What happens if I fail to submit this form?
Failing to submit the Ancillary Provider ID form can lead to delays in claims processing and credentialing. Providers without an established ID may face challenges in billing and receiving payments for services rendered.
- Claims Delays: Without submission, your claims processing may be significantly delayed.
- Loss of Credentials: Failure to submit could risk your status and credentialing with BCBSTX.
- Operational Issues: Providers may face operational difficulties without an active provider ID.
How do I know when to use this form?
- 1. New Providers: New healthcare providers entering the market must submit this form.
- 2. Change in Ownership: If a facility changes ownership, this form needs completion.
- 3. Adding Locations: Providers expanding through affiliate locations need to file this form.
- 4. License Updates: When updating licenses or contact info, this form is required.
- 5. Credentialing Status: Current providers needing to update their credentialing status must submit this form.
Frequently Asked Questions
How do I fill out the Ancillary Provider ID Form?
Gather the necessary details about your practice and fill in all required fields accurately.
Can I edit this form after downloading?
Yes, you can edit the PDF using PrintFriendly's editing tools before finalizing your document.
What documents do I need to attach?
You need to attach your facility license, W-9 form, and NPI confirmation.
How do I sign the PDF?
You can use the signing feature on PrintFriendly to add your signature directly to the document.
Is there a fee for using PrintFriendly?
No, using PrintFriendly to edit and manage your PDFs is free.
Can I share this form with others?
Yes, PrintFriendly allows easy sharing options for your PDFs.
What if I make a mistake while filling out the form?
You can edit the fields as needed before saving or printing the PDF.
What is the main purpose of this form?
The form is used to establish an Out-of-Network provider ID with BCBSTX.
How will I know if my submission was successful?
You will receive a confirmation letter once your Provider ID is established.
How can I contact support for issues with the form?
For assistance, you can reach out via the contact information provided in the form.
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