Checklists

These checklists can help guide you along the enrollment process.

• Individual

• Group/Practice
• In-State, Out-of-Network

Forms

The forms below apply to our prior enrollment process.

• Appendix D — For groups participating with BlueChoice^® HealthPlan.
• Application for Clinic/Group/Institution/Location to File Claims or to Change Employer Identification Number (EIN) — New group practices who want to join our networks can apply using this form.
• Authorization to Bill — Complete this form to notify BlueCross and BlueChoice that you have authorized a clinic, group, institution or location to bill for your services.
• Change of Address Form — Use this form to change your physical, pay to, correspondence and/or billing agency address.
• Clinical Laboratory Improvement Amendment (CLIA) Certification Verification Form — Complete this form for each location that renders lab services in the office.
• Doing Business As (DBA) Name Change Form — Complete this form to change the name of your office.
• Dental Enrollment Application — Non-medical dental providers (DDS or DMD) can apply for network enrollment using this form.
• EDIG ERA Enrollment Form/Clearinghouse and EDIG ERA Enrollment Form/Direct Submitter — Complete one of these forms to receive ERAs through our EDI Gateway (EDIG).

Note: Return the completed EDIG ERA Enrollment form to EDI.Services@bcbssc.com.  

• Electronic Funds Transfer (EFT) Application and Terms and Conditions — Complete this form to receive electronic payments.

Note: Return the completed form to Provider.EFT@bcbssc.com.

• Health Professional Application — For in-state, out-of-network providers only. 
• Hold Harmless Agreement — For groups participating with BlueChoice.
• Hold Harmless Agreement, Chiropractors — For chiropractors participating with BlueChoice.
• Nurse Practitioner Information Form — Complete this form to provide preceptor information for nurse practitioners.
• NPI Update Form — Use this form to register your National Provider Identifier (NPI) with BlueCross and BlueChoice.
• Provider Enrollment Application — New physicians and other health care professionals who want to join our networks can apply using this form.
• Registration Form for Mid-Level and Hospital-Based Providers — For mid-level and hospital-based providers who want to join non-Medicaid networks.

Note: Do not use this form if you are also applying for the Healthy Blue^SM (Medicaid) network. Use the Provider Enrollment Application.

• Request to Add or Terminate Provider Form — Add, terminate or change practitioner affiliation.

Note: If you are adding a practitioner to your group/location(s), please refrain from submitting claims until you receive notification from our Provider Enrollment department that your request has been completed and updates have been made in our system. All claims submitted prior to the system update must be resubmitted for processing.

• Satellite Location Application — Complete this form to notify BlueCross and BlueChoice of the creation of a new location for an enrolled group that wishes to file claims.
• South Carolina Uniform Managed Care Practitioner Credentials Update — Complete this form for recredentialing. Be sure to include the following documents:
  • Copy of your state license(s)
  • Copy of your current DEA registration (if applicable)
  • Proof of current malpractice insurance/COI (must be a minimum of $1MM/$3MM)
  • Clinical Laboratory Improvement Amendment (CLIA) Verification form (include a separate form for each location where you render lab services)

Note: Return these items via fax at 803-870-9997 or email them to Recred.App@bcbssc.com.

• Virtual Care Services Application — Complete this form for your practice to apply for participation with telemedicine and/or telehealth services. You can also view our frequently asked questions for more information.

Note: Email the completed application with supporting documentation to VirtualCare@bcbssc.com. 

Examples

These are examples of documents you may need to submit to us.

• Business License
• CMS Letter
• CMS PTAN Letter
• DEA Certification
• DHEC Certification
• Malpractice Coverage Verification
• IRS Document
• Nurse Protocols
• SC Medical License

BlueChoice HealthPlan is an independent licensee of the Blue Cross Blue Shield Association.