Contract Update Form: Nurse Practitioner-Primary Care Providers
Contract Update Form: Nurse Practitioner-Primary Care Providers
Contract Update Form: Nurse Practitioner-Primary Care Providers
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Group Practice Attachment<br />
Only complete this page if you are opening a new practice with a Type 2 NPI.<br />
Practice Administration<br />
Please list the names and titles of those who are authorized to sign contracts on behalf of the practice, such as Owner, Partner,<br />
President:<br />
Name<br />
Title<br />
Practice owner(s):<br />
Practice Members<br />
• Please list all NPPCPs in the practice. Attach an additional sheet if necessary.<br />
• Each NPPCP who is not currently credentialed by BCBSMA must also complete a BCBSMA <strong>Contract</strong>ing Application. If<br />
the group practice wishes to participate in our managed care plans, each NPPCP who is contracted with BCBSMA for the<br />
Indemnity Product only must also complete a <strong>Contract</strong>ing Application. You can download the application at<br />
www.bluecrossma.com/provider. Click on Become a Blue Cross Provider and select NPPCP.<br />
• Each NPPCP who is currently credentialed by BCBSMA must complete a separate <strong>Contract</strong> <strong>Update</strong> <strong>Form</strong> for NPPCPs.<br />
Log onto BlueLinks for <strong>Providers</strong> at www.bluecrossma.com/provider. Click the Resource tab and select <strong>Form</strong>s on the left<br />
side.<br />
• If the group participates in Medicare Advantage or is requesting to, an NPPCP who does not have a Medicare participating<br />
PTAN will not be enrolled in Medicare Advantage at this time. Please submit a new <strong>Contract</strong> <strong>Update</strong> <strong>Form</strong> for NPPCPs when<br />
you receive the NPPCP's individual Medicare participating PTAN. We may terminate the NPPCP's participation in your<br />
group BCBSMA agreement unless you submit his/her PTAN within six (6) months.<br />
Name NPI (Type 1) Individual Medicare PTAN *<br />
* If the group wishes to participate in Medicare Advantage, all NPPCPs must have active Medicare participating PTANs within six (6) months. If<br />
the NPPCP's PTAN is pending, please note the date he/she applied for status change.<br />
BCBSMA <strong>Contract</strong> <strong>Update</strong> <strong>Form</strong> for NPPCP – PEP-3296E (3/13) 6 of 6