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.
If you need instructions on how to obtain a contract for your Non‐Par Tax ID, click here.
Commercial PPO & Workers’ Compensation Network
Requesting a Contract For a Non-Participating Tax ID
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 08.21.15
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
*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 CAPhysicianApp@Anthem.com.
What Happens Next
The Anthem Blue Cross, California Physician Application Team 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, you may register by following the
prompts on the CAQH website at
https://upd.caqh.org/PR/Registration
.
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
https://proview.caqh.org or by phone at 1 (888)599‐1771.
Commercial PPO Individual, Group & CRNA
Agreement Packet Request 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 may 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
4) This form should NOT be used to add new physicians to your existing, Prudent Buyer PPO Group Contract. *This applies only to Dentists with a primary specialty of Oral Maxillo-Facial Surgery.
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:
Group (Type 2) NPI:
Primary Practice Address:
Practice Phone Number:
Physician 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 NPINumber CAQH# (or date of birth if no CAQH) Is the physician strictly hospital-based?
Please E-MAIL the completed form to CAPhysicianApp@Anthem.com.
Once we receive your request, please allow approximately 24-48 hours for processing. Please submit all status update requests/questions via email to CAPhysicianApp@Anthem.com. IMPORTANT: Our emails are often sent through a secure site, so please be sure to periodically check your SPAM folder for a response.
Commercial, PPO & Workers’ Compensation Network
Adding Physicians to Existing Group Contracts
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 08.21.15
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 Then
The Provider is a CRNA A completed CRNA Agreement is required. To request one, provide a Letter of Intent that includes your Group Tax ID, the CRNA’s Name and NPI and his/her Practice Location – including Zip Code.
Credentialing is NOT
required for Physician Complete the Physician Profile Form- signature and date required. Credentialing is required
for Physician 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# (You may register new physicians for a CAQH# by following the prompts at their website: https://upd.caqh.org/PR/Registration)
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. Note: Not required for CRNAs.STEP 4: E-Mail your request to Anthem at
CAPhysicianApp@Anthem.com
.
Note: Remember to include a “Hospitalist” or “Hospital-Based” letter in your email, if applicable.
What Happens Next
The Anthem Blue Cross, California Physician Application Team will review your completed Physician Profile Form or CAQH application. If credentialing is required, and all of the required elements are provided in CAQH, we will forward the application to the Credentialing Department. The review process may take up to 90 days. Once approved, the Credentialing department will send an approval letter to the physician and notify our Provider Database Department to add the physician to your contract.
If credentialing is not required, and all of the required elements are provided, we will forward the application to the Provider Database Department for loading.
RETURN FORM TO: Anthem Blue Cross, Prudent Buyer PPO Contracting at CAPhysicianApp@Anthem.com
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 08.21.15
Physician Profile Form
Name (Last, First, MI)/Provider Type (M.D., D.O., D.P.M.) Date of Birth: Gender:
Male Female Primary Practice Address (include city, state & zip):
Directory Display? Yes No
Primary Practice Telephone and Fax Number: PH#: Fax# Secondary Practice Address (include city, state & zip):
Directory Display? Yes No
Secondary Practice Telephone and Fax Number: PH#: Fax#
Mailing Address(If different from Practice Address): Credentialing Contact Name (regarding this form):
Phone# E-Mail:
Check / EOB Address (include city, state & zip): Practice/Office E-Mail Address:
Do you treat workers’ compensation patients?
Yes / No If not, list reason(s):
Office Mgr/Admin Name: Telephone and Fax Numbers:
PH#: Fax#
Languages (other than English) Spoken by Physician: Languages (other than English) Spoken by Staff:
List Current HOSPITAL Affiliations:
1. __________________________________
2. __________________________________
3. __________________________________
At least one HOSPITAL must be Anthem Blue Cross participating.
Note: The Admitting Hospital Verification form is required if you do not
have acceptable privileges or they are pending.
City/Campus where Hospital is Located
1. ___________________
2. ___________________
3. ___________________
Status (e.g., Active, Provisional, Courtesy, etc.)
1. __________________
2. __________________
3. __________________
Medical School (Include Graduation Date): Medical School City, State & Zip:
What is the Primary Specialty:
Board Cert? Yes No
Certifying Board: Lifetime: Yes No
Initial Cert Date: Re-Cert Date: Exp Date:
What is the Secondary Specialty:
Board Cert? Yes No
Certifying Board: Lifetime: Yes No
Initial Cert Date: Re-Cert Date: Exp Date:
Tax ID Number (for which physician is now being added/contracted): NPI Number
Individual : / Group:
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:
Delegated *Hospital-Based *Hospitalist PPO HMO Work Comp
*Hospitalist or Hospital-Based verification letter required.
ANTHEM USE ONLY
Per Diem Locum Tenens If temporary please indicate
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. Revised8.21.15
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:
Active Courtesy Provisional Affiliate 1. _______________________________ Attending Associate Full Temporary
Active Courtesy Provisional Affiliate 2. _______________________________ Attending Associate Full Temporary
Active Courtesy Provisional Affiliate 3. _______________________________ Attending Associate Full Temporary
__________________________________________ _____________________________ Signature of Physician Admitting Patients Physician’s Telephone Number __________________________________________ _____________________________ Physician’s California Medical License# 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)
