OK BCBS Group/Clinic Provider Enrollment Form 2020-2025 free printable template

GROUP/CLINIC PROVIDER ENROLLMENT FORM Complete the form and return to: EMAIL: OKNetworkManagement@bcbsok.com FAX: 9185492141 PHONE: 8007223730 (Option 2)MAIL: Blue Cross and Blue Shield of Oklahoma Attn:

How to fill out OK BCBS GroupClinic Provider Enrollment Form

How to fill out OK BCBS Group/Clinic Provider Enrollment Form

1. Gather necessary information: Ensure you have all required information such as National Provider Identifier (NPI), Tax Identification Number (TIN), and practice locations.
2. Obtain the form: Download the OK BCBS Group/Clinic Provider Enrollment Form from the Blue Cross Blue Shield of Oklahoma website.
3. Complete the provider information: Fill in details for the group or clinic, including legal name, DBA, and address.
4. Provide contact information: Enter the contact details for the person responsible for enrollment inquiries.
5. List all providers: Include all providers associated with the group or clinic, along with their NPI and relevant licensure information.
6. Attach supporting documents: Include any necessary documentation such as licenses, certifications, and Medicare enrollment confirmation.
7. Review the form: Double-check each section for accuracy and completeness.
8. Sign and date: Make sure the form is signed and dated by an authorized representative of the group or clinic.
9. Submit the form: Send the completed form and supporting documents to the designated address provided on the form.

Who needs OK BCBS Group/Clinic Provider Enrollment Form?

1. Health care providers and clinics wishing to participate in the Blue Cross Blue Shield of Oklahoma network.
2. New practices seeking reimbursement for services provided to BCBS members.
3. Existing practices that have had changes in ownership or structure that require re-enrollment.

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What is OK BCBS Group/Clinic Provider Enrollment Form?

The OK BCBS Group/Clinic Provider Enrollment Form is a document used by healthcare providers to enroll in the Oklahoma Blue Cross Blue Shield (BCBS) network, allowing them to offer services and receive reimbursements for covered patients.

Who is required to file OK BCBS Group/Clinic Provider Enrollment Form?

Healthcare providers, including group practices and clinics that wish to participate in the Oklahoma BCBS network and provide services to insured patients, are required to file the OK BCBS Group/Clinic Provider Enrollment Form.

How to fill out OK BCBS Group/Clinic Provider Enrollment Form?

To fill out the OK BCBS Group/Clinic Provider Enrollment Form, providers should gather all necessary information such as their NPI number, tax identification number, and practice details. Following the instructions provided on the form, they should complete each section fully and accurately, ensuring that all required supporting documents are attached before submitting.

What is the purpose of OK BCBS Group/Clinic Provider Enrollment Form?

The purpose of the OK BCBS Group/Clinic Provider Enrollment Form is to facilitate the enrollment of healthcare providers in the Oklahoma BCBS network, which allows them to provide healthcare services to covered individuals and receive appropriate reimbursement for those services.

What information must be reported on OK BCBS Group/Clinic Provider Enrollment Form?

The OK BCBS Group/Clinic Provider Enrollment Form must include information such as the provider's basic contact details, practice location, NPI number, tax ID, types of services offered, and banking information for direct deposit of claims payments.