Welcome to Anthem Blue Cross Blue Shield

New Provider Application Form

The New Provider Application Form should be used by Non-Credentialed and Ancillary Providers to apply for participation with Anthem Blue Cross and Blue Shield in Maine. The use of this form is limited to CMS-1500 claim format billers only. Credentialed Providers should use the Digital Provider Enrollment Application, available on the Availity portal and Health Delivery Organizations (HDOs) should use the Facility Application.

Refer to the Provider Type list for a list of Credentialed, Non-Credentialed, Ancillary, and Health Delivery Organization (HDO) provider types.

We encourage you to review the New Provider Application Form Instructions for more detailed information on the application process. Once all of the New Provider Application Form elements are completed, select the "Submit" button at the bottom of the form to complete the submission.

The IRS Tax Form W-9 is required when applying for participation with Anthem. The W-9 and any other required documentation must be submitted separately to:

Email: ProviderEducationCommunication@anthem.com (preferred method)

Fax: (207)-822-7726

Mailing Address:

Anthem Blue Cross and Blue Shield in Maine
Attn: Provider Solutions
Mail Stop: ME0102-W030
2 Gannett Drive
South Portland, ME 04106

Note: Do NOT use this form to request demographic or practice changes to existing, contracted providers, instead, proceed directly to the Provider Maintenance Form. (Copy and paste hyperlink into Google Chrome for best performance.)

What Happens Next

After you submit your completed application and all of the necessary supporting attachments, Anthem will review your application and send you a Provider Agreement that outlines the terms of your participation and the obligations of Anthem.

Once your application is processed, approved, and your signed Provider Agreement is received, Anthem will execute your Provider Agreement and notify you of your effective date. This notification will be delivered electronically via email, unless an email address is not available. (Note: Ensure emails from anthem.com do not default to your SPAM/JUNK folder.)

Please refrain from seeing Anthem Members as a participating provider until you have received Anthem's approval notification and effective date.

Anthem does NOT allow retroactive effective dates. If you file claims to us prior to the Anthem effective date notification, claims may process at the non-participating provider benefit level and Anthem will not be obligated to adjust affected claims, and you will not be permitted to balance bill the Member for the difference between your charge and the Anthem allowed amount.

Provider

Required Fields*
Ancillary Providers (Complete this section if you are on the Ancillary Provider Type list and to see information on "Closed" networks.)

Complete this section if you are one of the following provider types or suppliers: laboratory, ground or air ambulance, hearing aid distributer, durable medical equipment, home iv infusion therapy, immunization clinic, orthotic and prosthetic, cardiac event monitoring, or medical specialty pharmacy, etc. Before completing form, click here for important information about closed networks.

Effective date (This date is not a guarantee of participation. Complete only if future effective date, see Instructions.)

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 (This should represent your physical location)
Address line 2
City
State
County
Zip code
Phone
Fax
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 Maine?
Do you do business in Maine?
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.

Office hours Monday Start Time (hr:min)
Monday End Time (hr:min)
Tuesday Start Time (hr:min)
Tuesday End Time (hr:min)
Wednesday Start Time (hr:min)
Wednesday End Time (hr:min)
Thursday Start Time (hr:min)
Thursday End Time (hr:min)
Friday Start Time (hr:min)
Friday End Time (hr:min)
Saturday Start Time (hr:min)
Saturday End Time (hr:min)
Sunday Start Time (hr:min)
Sunday End Time (hr:min)

Identification numbers Tax Identification Number (TIN) (W-9 required, see top of form for submission details)
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
County
Zip code
Phone
Fax
Email

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

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 participation 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*

Attachments I have sent attachments separately.

By clicking on the button marked "SUBMIT" below, I agree as a condition of practicing in Maine, 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 Provider or am otherwise authorized to make this request and certification on behalf of the named Provider.

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Welcome to Anthem Blue Cross Blue Shield

New Provider Application Form

Provider

Ancillary Providers (Complete this section if you are on the Ancillary Provider Type list and to see information on "Closed" networks.)