Welcome to Anthem

New Provider Application Form

The New Provider Application Form should be used by Georgia physicians, providers and professionals to submit a request to join the networks for Blue Cross and Blue Shield of Georgia (BCBSGa).

Complete the CREDENTIALED PROVIDER section of this form if you have a completed up-to-date credentialing application with CAQH and require credentialing by BCBSGa. Click here to see a list of providers who require credentialing.

Complete the ANCILLARY PROVIDER section of the form if you are a lab, ground or air ambulance, hearing aid distributor, durable medical equipment, home IV, immunization clinic, orthotic and prosthetic, cardiac event monitoring, and medical specialty pharmacy. Before completing the application form, click here for important information about closed networks.

NON-CREDENTIALED PROVIDERS such as mid-levels (NPs, PAs, midwives, etc) and hospital based (anesthesia, pathology, radiology, emergency room, and hospitalists) should complete this section of the form. For a complete list of non-credentialed provider types click here.

What Happens Next

The BCBSGa Network Relations Department will review your application, request any required supporting documentation, and send the appropriate Agreement Packet to the email address listed in the "contact /submitter" field on your form. If there is no email address listed, please allow 6 weeks for mail delivery to the primary office mail address you provide below in this application form.

Please refrain from seeing BCBSGa members as an in-network provider until you have received notification of your network status.

Status of Submitted Applications

Ancillary Provider Application: To obtain information related to provider participation status and agreements, click on the "Ancillary Contact Information" link below to view the contact list of Ancillary Network Managers by provider specialty type. Based on your specialty, contact the designated representative.

Ancillary Provider Contact Information

Non-Credentialed or Credentialed Provider Application: Please allow 4 weeks for application review before checking application status. You may request status by sending an email containing the provider's name, tax ID number, and NPI to contractintake@bcbsga.com (Ancillary Providers should use the Ancillary Provider contact information listed above.)

Provider

Credentialed Providers

Complete the CREDENTIALED PROVIDER section of this form if you have a completed up-to-date credentialing application with CAQH and require credentialing by BCBSGa. Click here to see a list of providers who require credentialing.

Provider information Provider last name
Provider first name
Provider middle initial
Provider suffix
Provider professional title
Individual National Provider Identifier (NPI)
Individual Provider Tax Identification Number (TIN)
What type of provider are you?
Other
Primary specialty
Other
Provider's self-reported area of expertise (primary) (behavioral health providers only)
Provider's self-reported area of expertise (secondary) (behavioral health providers only)
Do you practice exclusively within an inpatient setting? (If yes, STOP and complete the form section titled Non - Credentialed providers )
Do you have an active CAQH ID number?*
If yes, what is your CAQH ID number?*
Have you given permission for the health plan to access your CAQH information?*
Please list your patient minimum age preference
Please list your patient maximum age preference
Please list your patient gender preference.
In which state is your primary office located?
Are you a new provider or addition to an existing contracted group?
Do you participate in a IPA or PHO?
If yes, provide name of affiliation

Medicare/Medicaid participation Are you a participating Medicare provider?
Medicare provider number
Are you a participating Medicaid provider?
Medicaid provider number

Primary practice office Corporate name as it appears on W-9
Practice/DBA name (if different from above)
Address line 1
Address line 2
City
State
County
Zip code
Phone
Fax
Practice correspondence email
Practice Tax Identification Number (TIN)
Organizational National Provider Identifier (NPI)

Correspondence Address Address line 1
Address line 2
City
State
County
Zip code
Phone number
Fax number

Contact/Submitter (person submitting the form) Last name*
First name*
Phone*
Fax*
Contact email*
Ancillary providers

Complete this section if you one of these provider types: lab, ground or air ambulance, hearing aid distributor, durable medical equipment, home IV, immunization clinic, orthotic and prosthetic, cardiac event monitoring, or medical specialty pharmacy. Before completing form, click here for important information about closed networks.

If not this provider type, go to the form section for NON CREDENTIALED PROVIDERS.

Provider information What type of provider are you?
Corporate name as it appears on W-9
Company/DBA name (if different from above)
Address line 1
Address line 2
City
State
County
Zip code
Office phone number
Office fax number
Office email address
Website
Will you be providing services at additional locations under this TIN?
If yes, list complete addresses and phone numbers for all additional locations.
Do you have a physical location in Georgia?
Do you do business in Georgia?
What counties will you serve? (Please indicate 'all', or list specific counties you will serve)
Does this office provide handicapped accessibility?
24x7 phone coverage at this location?
Please list any non-English languages spoken by office personnel.
Please list your patient minimum age preference
Please list your patient maximum age preference
Please list your patient gender preference.

Office Hours Monday Start Time
Monday End Time
Tuesday Start Time
Tuesday End Time
Wednesday Start Time
Wednesday End Time
Thursday Start Time
Thursday End Time
Friday Start Time
Friday End Time
Saturday Start Time
Saturday End Time
Sunday Start Time
Sunday End Time

Identification numbers Tax Identification Number (TIN)
Organizational National Provider Identifier (NPI)
State license number
License state
Additional licensure as applicable (e.g. Pharmacy License, DHR Clinical Lab License, State Hearing Aid Dispenser License, etc.)
Accrediting/Certifying Program (e.g. CLIA, COLA, MLE, AAFP, CAP, etc.)
Are you a participating Medicare provider?
Medicare provider number
Do you have Medicare certification?
Are you a participating Medicaid provider?
Medicaid provider number

Payment/Remittance address Address line 1
Address line 2
City
State
Zip code
Phone
Fax
Email

Correspondence Address Address line 1
Address line 2
City
State
County
Zip code
Phone number
Fax number

Licensure Has the organization or company license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, or restricted?
If yes, please provide an explanation.
Has the organization or company ever been subject to a fine, reprimand, consent order, or probation?
If yes, please provide an explanation.

Governmental Program Has the organization or company ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental agency?
If yes, please provide an explanation.

Contact/Submitter (person submitting form) Last name*
First name*
Phone*
Fax*
Contact email*
Non-Credentialed Providers

NON-CREDENTIALED PROVIDERS such as mid-levels (NPs, PAs, midwives, etc) and hospital based (anesthesia, pathology, radiology, emergency room, and hospitalists) should complete this section of the form. For a complete list of non-credentialed provider types click here

Provider information Last name
First name
Middle name
Suffix
Provider professional title
Individual National Provider Identifier (NPI)
Individual Provider Tax Identification Number (TIN)
If provider has used other names, please include here.
Birth date
Gender
Non-English languages spoken by provider
Non-English languages spoken by office personnel
Please list your patient minimum age preference
Please list your patient maximum age preference
Please list your patient gender preference.

Provider Type/Specialty What type of provider are you?
Other
Primary specialty
Other
Are you board certified?
Name of certifying board
Secondary specialty
Other
Are you board certified?
Name of certifying board

Medical license State license number
License state
Do you currently practice in this state?
License status

DEA registration Do you have a DEA registration certificate?
Federal DEA number
Federal DEA state of registration (if applicable)
Federal DEA expiration date

Medicare/Medicaid participation Are you a participating Medicare provider?
Medicare provider number
Are you a participating Medicaid provider?
Medicaid provider number

Internship or residency State
Country
Institution/Hospital name
Department
Graduation Date

Area(s) of expertise (behavioral health providers only) Provider's self-reported area of expertise
Provider's self-reported area of expertise
Other Interests
Provide additional areas of professional practice interest, activities, procedures, diagnoses or populations, ex. HIV/AIDS

Primary practice information Corporate name as it appears on W-9
Practice/DBA name (if different from above)
Address line 1
Address line 2
City
State
County
Zip code
Phone
Fax
Practice/Correspondence email
Tax Identification Number (TIN)
Organizational National Provider Identifier (NPI)
Will provider be practicing at additional locations under this TIN?
If yes, provide complete addresses and phone numbers for additional locations
Do you participate in a PMG, IPA or PHO?
If yes, provide name of affiliation
Do you accept new patients into the practice?
Does this office provide handicapped accessibility?

Office Hours Monday Start Time
Monday End Time
Tuesday Start Time
Tuesday End Time
Wednesday Start Time
Wednesday End Time
Thursday Start Time
Thursday End Time
Friday Start Time
Friday End Time
Saturday Start Time
Saturday End Time
Sunday Start Time
Sunday End Time

Additional information Payment/Remittance address
Address line 1
Address line 2
City
State
Zip code
County
Phone
Fax
Email

Correspondence Address Address line 1
Address line 2
City
State
County
Zip code
Phone number
Fax number

Practice Limitations Are there any age limitations?
Minimum age limitation
Maximum age limitation
Other limitation description

Hospital admitting privileges Do you have hospital privileges?
If no, what admitting arrangements do you have?
Hospital name

Licensure Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, or restricted?
If yes, please provide an explanation.
Have you ever been subject to a fine, reprimand, consent order, or probation?
If yes, please provide an explanation.

Governmental Program Participation Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental agency?
If yes, please provide an explanation.

Contact/Submitter (person submitting form) Last name*
First name*
Phone*
Fax*
Email*

By clicking on the tab marked "SUBMIT" below, I agree as a condition of practicing in Georgia, to be subject to the jurisdiction and disciplinary authority of the appropriate agency. In addition, I hereby request the above changes and certify that the foregoing information is true and correct and that I am the named professional or am otherwise authorized to make this request and certification on behalf of the named professional.

To submit form ensure any sections that are not being populated are collapsed/closed.

Serving Georgia

Welcome to Anthem

New Provider Application Form

Provider

Credentialed Providers

Ancillary providers

Non-Credentialed Providers