This New Provider Application Form should be used by Colorado physicians, practitioners, professionals and ancillary providers to apply for participation, or to add a provider to an existing group, with Anthem Blue Cross and Blue Shield.
Complete the CREDENTIALED PROVIDER section below if you have a completed up-to-date credentialing application with CAQH and require credentialing by Anthem. Click here for a list of provider types that require credentialing by Anthem. Before completing the application form, click here for important information about closed networks.
Complete the ANCILLARY PROVIDER section if you are one of the following 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 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. (* If a Nurse Practitioner is requesting participation as a Primary Care Physician (PCP) directly with Anthem, credentialing is required effective January 1, 2015).
What Happens Next?
After processing your application, you will receive correspondence from Anthem's Provider Solutions department to notify you of the outcome.
You cannot begin seeing Anthem members as an in-network Provider until after you receive notification of approval from Anthem (if joining an existing group), or have completed a fully executed Agreement, which will include your effective date.
If you file claims to us before the effective date, claims may process at the non-participating provider benefit level and Anthem will not be obligated to adjust affected claims.
By clicking on the tab marked "SUBMIT" below, I agree as a condition of practicing in Colorado, 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.
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