New documents, instructions, fax number available for nonhospital facility form submissions

In April, a new, easier-to-use nonhospital facility record update form and network agreement and signature documents were made available on the upgraded Facility Provider Enrollment website.

These nonhospital facilities forms include:

• BCBSM/BCN New Facility Enrollment Form
• BCBSM/BCN Facility Change Form
• Network agreement and signature documents — required for facilities wishing to participate in additional networks or for new facilities doing business with BCBSM and BCN (Network approvals are made after credentialing is completed.)

To download these forms, go to bcbsm.com/providers.

• Under Join the Blues Network, click on Enrollment.
• Click on Provider Enrollment.
• Click on Hospitals and Facilities.
• Select the type of facility.

Starting July 1, please follow these new instructions to submit enrollment forms:

• The fax cover sheet must be the first page of your submission.
• Fax the enrollment form and attachments (for example, contract signature documents) to 1-866-900-0250. Be sure to fax the registration information separately for each facility. (For example, if you register two or more facilities, you must complete and send a separate form and fax for each facility. They cannot be bundled into one fax transmission.)
• You can also mail the completed forms and documentation to:
  • Provider Enrollment and Data Management
  • Blue Cross Blue Shield of Michigan
  • Mail Code C334
  • P.O. Box 217
  • Southfield, MI 48034

If you have any questions about nonhospital facility enrollment, call Provider Enrollment and Data Management at
1-800-822-2761.

If you have any questions about hospital enrollment, call BCBSM Hospital Contracting at 313-448-7892.