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1 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.

2 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 *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 the Agreement Packet Request Form to What Happens Next The Anthem Blue Cross, California Physician Application Team will review your request, determine the physician s credentialing status, then the pertinent agreement packet to the 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 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 or by phone at 1 (888) For any questions regarding the contracting process, or if you would like to check the status of your application, you may us at NOTE: If credentialing is required, the review 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

3 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 Address: We are also interested in being displayed as an Urgent Care Center: Y / N address for Packet- if different from above: Primary Practice Address: Tax ID: Business Name: Group (Type 2) NPI: 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 NPI Number CAQH# (or date of birth if no CAQH) Is the physician strictly hospitalbased? Please the completed form to Once we receive your request, please allow approximately hours for processing. Please submit all status update requests/questions via to IMPORTANT: Our s are often sent through a secure site, so please be sure to periodically check your SPAM folder for a response. 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

4 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 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 Complete the Physician Profile Form- signature and date required. required for Physician Credentialing is required Write a Letter of Intent (on your letterhead) requesting to add the physician to your for Physician 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: 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: your request to Anthem at Note: Remember to include a Hospitalist or Hospital-Based letter in your , 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. If you have any questions regarding the contracting process or would like to check the status of your application, please us at 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

5 Physician Profile Form Delegated *Hospital-Based *Hospitalist PPO HMO Work Comp *Hospitalist or Hospital-Based verification letter required. Per Diem Locum Tenens If temporary please indicate Neither expected duration: ANTHEM USE ONLY 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): Primary Practice Telephone and Fax Number: Directory Display? Yes No Secondary Practice Address (include city, state & zip): Directory Display? Yes No Mailing Address(If different from Practice Address): PH#: Fax# Secondary Practice Telephone and Fax Number: PH#: Fax# Credentialing Contact Name (regarding this form): Check / EOB Address (include city, state & zip): Phone# Practice/Office 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: 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. Medical School (Include Graduation Date): City/Campus where Hospital is Located Medical School City, State & Zip: Status (e.g., Active, Provisional, Courtesy, etc.) What is the Primary Specialty: What is the Secondary Specialty: Board Cert? Yes No Certifying Board: Lifetime: Yes No Initial Cert Date: Re-Cert Date: Exp Date: Certifying Board: Lifetime: Yes No Board Cert? Yes No Tax ID Number (for which physician is now being added/contracted): Initial Cert Date: Re-Cert Date: Exp Date: 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: RETURN FORM TO: Anthem Blue Cross, Prudent Buyer PPO Contracting at 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

6 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 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

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