If you need instructions on how to obtain a contract for your

If you need instructions on how to obtain a contract for your Non-Par Tax ID, click here.
If you need instructions on how to add Physicians to your existing Group Contract, click here.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent
licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered
marks of the Blue Cross Association.
Commercial PPO & Workers’ Compensation Network
Requesting a Contract For a Non-Participating Tax ID
How to Request a Contract for Your Non-par Tax ID: Follow the steps below to receive
Anthem’s commercial PPO & Workers’ Compensation contract packet.
STEP 1: Determine if you are eligible for participation.
We offer commercial PPO & Worker’s Compensation contracts to the following provider types*:
•
•
•
M.D.
D.O.
(CRNA) Certified Registered Nurse
Anesthetist
•
•
D.P.M.
D.D.S. / D.M.D. – with a primary specialty of
Oral Maxillo‐Facial Surgery, provide medical
benefits for TMJ, Sleep Apnea and/or oral facial
pain
*If your license type is not listed above, please refer to our website to determine the appropriate network based on your specialty.
STEP 2: Complete and e-mail the Agreement Packet Request Form to [email protected].
What Happens Next
Anthem Blue Cross, CA Contracting Support will review your request, determine the physician’s credentialing
status, then email the pertinent agreement packet to the e-mail address you’ve provided.
Note: If credentialing is required, Anthem Blue Cross participates in the Council for Affordable Quality
Healthcare (CAQH). CAQH, a non-profit alliance of the nation’s leading health plans and networks, has
developed a national database for credentialing information. The use of this database, which is compliant
with California State and National Accreditation requirements, allows physicians a secure, online format for
storage and communication of credentialing and practice information. IMPORTANT: We do not accept
printouts of the CAQH Data Summary screens or CPPAs (California Participation Physician Applications). All
information must be available for viewing online via the CAQH website.
If you do not have a CAQH Provider ID and credentialing is required, we will request one for you and include
it with your contract packet.
If you already have a CAQH user ID, please review your profile and confirm that you have granted reading
rights to Anthem Blue Cross. If you have not and need help, please contact CAQH via their website
at http://www.caqh.org/ or by phone at 1 (888)599-1771.
For any questions regarding the contracting process, or if you would like to check the status of your
application, you may email us at [email protected]. NOTE: If credentialing is required,
processing can take up to 90 days.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent
licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered
marks of the Blue Cross Association.
Revised 01.06.15
Commercial PPO Individual, Group & CRNA
Agreement Packet Request Form
When to use this form
1) This form should be used if you are interested in participating with Anthem Blue Cross’ Commercial PPO and
Workers’ Compensation networks for medical services.
2) This form should only be used by Physicians, Certified Registered Nurse Anesthetists or Dentists* practicing in
California.
3) To begin the process you must possess 1) an unrestricted Medical, Dental or Nurse Anesthetist License, 2) an
individual National Provider Identifier Number (a.k.a., Type 1 NPI), and 3) a Tax Identification Number
*This applies only to Dentists with a primary specialty of Oral Maxillo-Facial Surgery, or who provide medical benefits for TMJ, Sleep Apnea
and/or oral facial pain.
Contact Name:
Contact e-Mail Address:
We are also interested in being displayed as an Urgent Care Center:
Y/
N
E-Mail address for Packet- if different from above:
Tax ID:
Business Name:
Primary Practice Address:
Practice Phone Number:
Physician/Dentist or CRNA
Name
If you have more than 5 providers on your
roster, please attach a separate sheet
Primary and
Secondary
Specialties
License No.
(including
prefix)
Individual NPI
Number
CAQH#
(or date of
birth if no
CAQH)
Is the
physician
strictly
hospitalbased?
Please e-mail the completed form to CA Contracting Support at [email protected].
Once we receive your request, please allow approximately 24-48 hours for processing. Please submit all status update
requests/questions via email to [email protected].
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Revised 01.06.15
Commercial, PPO & Workers’ Compensation Network
Adding Physicians to Existing Group Contracts
How to Add Physicians to your Group Contract - Follow the steps below to add new Physicians or
Certified Registered Nurse Anesthetists (CRNA) to your existing PPO or Workers’ Compensation contract.
STEP 1: Determine if Credentialing is Required
If any of the following apply, credentialing may not be required for your physician
• The provider is a CRNA, strictly hospital-based or a hospitalist (a letter specifying the physician is a
“hospitalist” or “hospital-based” is required and must include his/her name, specialties and affiliated
hospital)
• The physician is part of a delegated medical group that has made arrangements with Anthem Blue Cross to
handle the credentialing process (you may contact us to verify this arrangement if you are unsure)
• The physician is already an existing PPO provider under a different Tax ID and was successfully credentialed
within the last three years (you may contact us to verify this information if you are unsure)
STEP 2: Complete the Appropriate Form/Letter
If
The Provider is a CRNA
Credentialing is NOT required
for Physician
Credentialing is required for
Physician
Then
Complete the Agreement Packet Request Form
Complete the Physician Profile Form- signature and date required.
Write a Letter of Intent (on your letterhead) requesting to add the physician
to your contract. The letter must include all of the following:
• Group Tax ID
• Physician’s Name
• Physician’s Type 1 NPI (Individual)
• Physician’s License Number
• Physician’s CAQH# (or DOB, if he/she doesn’t have a CAQH#)
STEP 3: Complete the Admitting Hospital Verification form, if the physician does not have admitting
privileges to one of Anthem Blue Cross’ participating hospitals in California.
STEP 4: E-Mail your request to Anthem at [email protected].
Note: Remember to include a “Hospitalist” or “Hospital-Based” letter in your email, if applicable.
What Happens Next
Anthem Blue Cross, CA Contracting Support will review your completed Physician Profile Form or CAQH application. If all of the
required elements are provided, we will either forward the request to add the physician to your Contract to our Database
Department, or our Credentialing Department, whichever is applicable. Note: If credentialing is required, the review process can
take up to 90 days.
If your physician requires credentialing, but does not have a CAQH user ID #, we will assign one and email it to you. Once you have
completed the CAQH online application and receive a confirmation email from CAQH, please resubmit your Letter of Intent to
Anthem Blue Cross. Once received, we will begin the credentialing process.
If you have any questions regarding the contracting process or would like to check the status of your application, please email us
at [email protected].
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent
licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered
marks of the Blue Cross Association.
Revised 01.06.15
Physician Profile Form
Delegated
*Hospital-Based
*Hospitalist
PPO
HMO
Work Comp
*Hospitalist or Hospital-Based verification letter required.
ANTHEM USE ONLY
Name (Last, First, MI)/Provider Type (M.D., D.O., D.P.M.)
Date of Birth:
Primary Practice Address (include city, state & zip):
Primary Practice Telephone and Fax Number:
(
Directory Display?
Yes
No
Secondary Practice Address (include city, state & zip):
Gender:
Male
Female
)
(
)
Secondary Practice Telephone and Fax Number:
(
)
(
)
Directory Display?
Yes
No
Mailing Address(If different from Practice Address):
Credentialing Contact Name (regarding this form):
Check / EOB Address (include city, state & zip):
Phone (
)
Office E-Mail Address:
Do you treat workers’ compensation patients?
Office Manager / Administrator Name:
Yes
/ No
E-Mail:
If not, list reason(s):
Telephone and Fax Numbers:
(
)
(
)
Languages (other than English) Spoken by Physician:
Languages (other than English) Spoken by Staff:
List Current Hospital Affiliations:
City/Campus where Hospital is
Located
1.
__________________________________
2.
__________________________________
3.
__________________________________
Status (e.g., Active, Provisional,
Courtesy, etc.)
1.
___________________
1.
__________________
2.
___________________
2.
__________________
3.
___________________
3.
__________________
At least one hospital must be Anthem Blue Cross participating.
Note: The Admitting Hospital Verification form is required if you do not
have required privileges.
Medical School (Include Graduation Date):
Medical School City, State & Zip:
Primary Specialty
/ Board Certified?
Yes
No
Secondary Specialty
/ Board Certified?
Yes
No
Certifying Board:
Initial Cert Date:
Re-Cert Date:
Certifying Board:
Initial Cert Date:
Tax ID Number (for which physician is now being added/contracted):
Lifetime:
Re-Cert Date:
CA License Number:
Expiration Date:
CAQH Number:
DEA Number (CA Practice):
Expiration Date:
Malpractice Carrier/Policy Number:
Malpractice Coverage Amt:
/
Expiration Date:
Physician Signature and Date:
RETURN FORM TO:
No
Yes
No
Exp Date:
Lifetime:
NPI Number
Individual :
Yes
Exp Date:
/ Group:
Anthem Blue Cross, California Contracting Support at [email protected]
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association
Revised 01/06/14
Admitting Hospital Verification Form
Dear Physician,
In order to be eligible to become a contracted provider, you must have admitting privileges to an Anthem
Blue Cross participating hospital or one of the following:
a) Arrangement with a network physician to provide inpatient care at an Anthem Blue Cross
participating hospital or
b) Arrangement to admit patients through a Hospitalist Program at an Anthem Blue Cross
participating hospital
Based on your arrangement, please complete one of the applicable sections below.
SECTION A – Another physician admits patients on my behalf
This section must be completed by the ADMITTING PHYSICIAN. Note: Admitting physician must practice in the
same specialty as the physician he/she is admitting patients on behalf of, in addition to maintaining admitting
privileges at an Anthem Blue Cross participating hospital. Please print clearly.
I, Dr. _________________________________________________________________ admit patients for
Dr. ______________________________. I have privileges at the following Anthem Blue Cross participating hospitals:
Please check any of the following:
1. _______________________________
Active
Attending
Courtesy
Associate
Provisional
Full
Affiliate
Temporary
2. _______________________________
Active
Attending
Courtesy
Associate
Provisional
Full
Affiliate
Temporary
3. _______________________________
Active
Attending
Courtesy
Associate
Provisional
Full
Affiliate
Temporary
__________________________________________
Signature of Physician Admitting Patients
__________________________________________
Physician’s California Medical License#
_____________________________
Physician’s Telephone Number
_____________________________
Date
SECTION B – I admit patients through a Hospitalist Program
The Hospitalist Program must admit to an Anthem Blue Cross participating hospital on the enclosed list.
I, Dr. __________________________________________________ have arranged to admit patients through
(Name of Hospitalist Program)
That admits to: __________________________________________________________________________.
(Name of Anthem Blue Cross participating hospital)
___________________________________
Physician Signature
___________________
Date
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are
independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol are registered marks of the Blue Cross Association.
Revised 01/06/15