Contract Update Form: Nurse Practitioner-Primary Care Providers

Contract Update Form
Nurse Practitioner-Primary Care Providers
Fax completed form to 617-246-4227.
Questions Please call 1-800-316-BLUE (2583).
..............................................................................
Use this form to notify BCBSMA* of a change to a contracted NPPCP's practice status, etc. as listed below. Please retain a
copy of this completed form for your files. If needed, new contracts will be mailed for you to complete and return.
NPPCPs may only be enrolled by BCBSMA at one practice and may not be separately enrolled as a Nurse Practitioner.
You cannot provide covered services and be reimbursed as a participating provider in any new practice or new Product until
notified by BCBSMA that the ensuing contract is in effect.
Please indicate the change(s) you would like to make by checking the appropriate box(es). Complete sections 1 through 4 as
applicable, in addition to sections noted below.
You are an NPPCP joining or opening a new practice as an NP. This means you will no longer be enrolled as an NPPCP.
Please submit the Contract Update Form for Ancillary Advanced Practice Nurses instead, available on BlueLinks for
Providers.
You are an NPPCP leaving your current practice and joining, as an NPPCP, a new practice that will bill for your services
on a 1500 claim form (please complete all sections)
You are changing your Tax ID number (also complete sections 13, 14, 15)
You wish to add a Product to your Agreement (also complete sections 14, 15)
You are changing your Collaborating Physician (also complete sections 7, 8, 14)
You are changing a hospital affiliation (also complete sections 12, 14)
Other (please explain):
Section 1. Individual Practitioner Information
Name:
License number:
National Provider Identifier (NPI Type 1):
Email:
Check your specialty: Family Medicine Internal Medicine Pediatrics
Section 2. BCBSMA Product Participation
• To add a Product, please check all Products that you want to participate in.
• If you are joining a group practice, you must be enrolled in the same Products that the group participates in.
If the practice participates in Medicare Advantage, you must obtain a Medicare participating Provider Transaction Access
Number (PTAN) unless your specialty is pediatrics.
• If you are remaining as an independently practicing provider only, please check all Products in which you wish to participate.
To participate in Medicare Advantage, you must provide your Medicare participating PTAN below.
Medicare Advantage HMO Medicare Advantage PPO HMO PPA Indemnity
Section 3. Medicare Participation Status
Please select one of the following:
You are a Medicare B participating provider with a current, valid, and active Medicare participating PTAN. The PTAN(s)
below indicate that you have signed a Medicare B provider agreement and accept assignment in all cases.
Individual Medicare
participating PTAN:
This section continues on the next page
Group Medicare participating
PTAN (if applicable):
* BCBSMA refers to Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue ® , Inc., and/or
Massachusetts Benefit Administrators LLC, based on Product participation.
® Registered Mark of the Blue Cross Blue Shield Association.
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Your PTAN is currently pending or you have applied for but not yet received a PTAN. Date you applied:
You will not be enrolled in Medicare Advantage at this time. If you check this box when joining a group that participates in
Medicare Advantage, you must submit a new Contract Update Form for NPPCPs with your Medicare participating PTAN
within six (6) months. We'll send you new contracts to complete and return. We may terminate your participation in
the group's BCBSMA agreement unless you submit your PTAN within six (6) months.
A Medicare participating PTAN is not required because:
• neither the group practice you are joining nor your Collaborating Physician participate in Medicare Advantage, or
• you are an independently practicing provider and not applying for participation in Medicare Advantage, or
• your specialty is pediatrics only.
Section 4. Existing Practices
Each location must have a separate, designated space in which to provide care to patients, to ensure patient privacy during
treatment.
Practice name:
DBA (as reported to the IRS):
Practice Tax ID number:
Practice NPI (Type 2):
Practice Address:
Email:
City, State, Zip code:
Phone to schedule appointments: ( ) Fax: ( )
Additional locations
You provide services at additional sites that bill using the same NPI as above (please attach a list)
Billing address Same as above Other:
Billing name:
Address:
City, State, Zip code:
Email:
Phone: ( ) Fax: ( )
Additional Existing Practice
Practice name:
DBA (as reported to the IRS):
(if applicable: a practice using a separate Tax ID number and Type 2 NPI)
Practice Tax ID number:
Practice NPI (Type 2):
Practice Address:
Email:
City, State, Zip code:
Phone to schedule appointments: ( ) Fax: ( )
Additional locations
Section 5. Leaving a Practice
You provide services at additional sites that bill using the same NPI as above (please attach a list)
Please note: By leaving a practice, you will also be leaving the Product participation associated with that practice. You must
indicate in section 2 the Products in which you now wish to participate.
If leaving all BCSMA practices, submit the Enrollment Update Form for Professional Providers instead of this form.
Please check this box if you are enrolled as a Nurse Practitioner-Primary Care Provider at this practice and will be
terminating your NPPCP status to join a new practice as a Nurse Practitioner.
Date leaving practice:
Practice name:
Practice NPI (Type 2):
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Practice Address:
City, State, Zip code:
Phone: ( )
Section 6. Joining or Opening a New Practice as a Nurse Practitioner-Primary Care Provider
Your NPPCP status at your current practice will end when we enroll you as an NPPCP at this new practice.
In section 2, please indicate the Products you wish to participate in at this practice.
If your group has a new Tax ID and Type 2 NPI, please also complete the Group Practice Attachment.
Employment or start date:
Practice name:
DBA (as reported to the IRS):
Practice Tax ID number:
Practice NPI (Type 2):
Practice Address:
City, State, Zip code:
Phone to schedule appointments: ( ) Fax: ( )
Additional locations
You provide services at additional sites that bill using the same NPI as above (please attach a list)
Billing address Same as above Other:
Billing name:
Address:
City, State, Zip code:
Email:
Phone: ( ) Fax: ( )
Section 7. Collaborating Arrangement
This section is required if you are joining or opening a practice.
Please indicate your Collaborating (“supervising”) Physician(s). Each Collaborating Physician listed below must complete the
Practice Guidelines Statement (see section 8). The Collaborating Physician must be participating with BCBSMA in the same
Products that you indicated in section 2.
Physician Name Physician Specialty NPI
Section 8. Practice Guidelines Statement
This section is required if you are joining or opening a practice
or changing your Collaborating Physician.
Please sign and date this section, then have it signed and dated by your Collaborating Physician(s).
By checking this box and signing below, the physician attests that he or she has developed and signed mutually agreedupon,
written practice guidelines for the NPPCP whose name appears below.
Collaborating Physician signature:
(signature stamp not accepted)
Collaborating Physician name:
Date of physician signature:
NPPCP signature:
(signature stamp not accepted)
NPPCP name:
Date of NPPCP signature:
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Section 9. Covering Arrangement
This section is required if you are joining or opening a practice.
Arranging for 24-hour coverage is a credentialing and contractual requirement. Please list the physicians and/or groups that
provide coverage for you. Covering providers must be participating in the same Products that you are requesting.
Physician or Group Practice Name
NPI
Section 10. Hospital Privileges
Please complete the following chart as it relates to your hospital affiliation and admitting arrangements.
Your hospital affiliation must be a BCBSMA contracted acute care hospital and your admitting provider must be a BCBSMA
credentialed and contracted physician.
Hospital Affiliation
If you have a hospital affiliation, please provide the name of your primary acute care hospital:
__________________________________________________________________________________
If you are affiliated with secondary acute care hospital(s) and wish to have it/them listed in the directory,
please provide the name(s):
Admitting
Privileges at
Primary Acute Care
Hospital
__________________________________________________________________________________
If you have admitting privileges at the
primary acute care hospital named above,
please check this box:
If you do not have admitting privileges at your primary acute
care hospital, please indicate below who provides
arrangements for your inpatient admissions.
Check all applicable boxes:
My Collaborating Physician as indicated in section 7
The physicians affiliated with the practice in section 4
Covering physicians not affiliated with the practice in
section 4
Please note: Your covering party must complete, sign and
date section 11, Admitting Arrangement Attestation.
Section 11. Admitting Arrangement Attestation
Please have this section signed and dated by a physician who provides arrangements for your inpatient admissions.
By checking this box and signing below, the physician affirms and represents that the practice or hospitalist program name
(“covering party”) listed below provides all arrangements for inpatient admissions for the NPPPCP whose name appears
below. This arrangement will continue until such time as the NPPCP obtains admitting privileges in good standing at an
acute care hospital that is participating with BCBSMA.
Physician signature:
(signature stamp not accepted)
Physician name and title:
Date of physician signature:
Name of covering party:
Phone: ( )
NPPCP name:
Section 12. Hospital Affiliation
You (the NPPCP) are: changing your primary hospital affiliation
Name of hospital (required):
Initial date of appointment (MM/DD/YY):
adding a secondary hospital affiliation
Does your current professional staff status include admitting privileges Yes No
BCBSMA Contract Update Form for NPPCP – PEP-3296E (3/13) 4 of 6

Section 13. New Form W-9
A new W-9 is required to verify new billing information. If you are joining a contracted group, you do not need to submit a W-9.
The attached IRS Form W-9 has been completed with the name and Tax ID number to which payments will be directed.
Section 14. Representations
By checking this box, you hereby affirm and represent that all statements, answers, and information included in this
Contract Update Form are true and complete to the best of your knowledge and belief, and that you are duly authorized to
provide information on behalf of the NPPCP named in section 1.
Name of person completing form:
Title:
Practice name:
Email:
Phone: ( ) Fax: ( )
Date:
Section 15. Contract Recipient
Where we should mail contract documents: Existing practice address in section 4 Billing address in section 4 Other:
Attention of:
Address:
City, State, Zip code:
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Group Practice Attachment
Only complete this page if you are opening a new practice with a Type 2 NPI.
Practice Administration
Please list the names and titles of those who are authorized to sign contracts on behalf of the practice, such as Owner, Partner,
President:
Name
Title
Practice owner(s):
Practice Members
• Please list all NPPCPs in the practice. Attach an additional sheet if necessary.
• Each NPPCP who is not currently credentialed by BCBSMA must also complete a BCBSMA Contracting Application. If
the group practice wishes to participate in our managed care plans, each NPPCP who is contracted with BCBSMA for the
Indemnity Product only must also complete a Contracting Application. You can download the application at
www.bluecrossma.com/provider. Click on Become a Blue Cross Provider and select NPPCP.
• Each NPPCP who is currently credentialed by BCBSMA must complete a separate Contract Update Form for NPPCPs.
Log onto BlueLinks for Providers at www.bluecrossma.com/provider. Click the Resource tab and select Forms on the left
side.
• If the group participates in Medicare Advantage or is requesting to, an NPPCP who does not have a Medicare participating
PTAN will not be enrolled in Medicare Advantage at this time. Please submit a new Contract Update Form for NPPCPs when
you receive the NPPCP's individual Medicare participating PTAN. We may terminate the NPPCP's participation in your
group BCBSMA agreement unless you submit his/her PTAN within six (6) months.
Name NPI (Type 1) Individual Medicare PTAN *
* If the group wishes to participate in Medicare Advantage, all NPPCPs must have active Medicare participating PTANs within six (6) months. If
the NPPCP's PTAN is pending, please note the date he/she applied for status change.
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Form W-9
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Name (as shown on your income tax return)
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate
Exempt payee
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Social security number
– –
Employer identification number
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person ▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Date ▶
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231X Form W-9 (Rev. 12-2011)
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