Welcome to Anthem Blue Cross and Blue Shield

New Provider Application Form

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).

An IRS W-9 form must be submitted separately to: Email: PE&CCOCredentialing@anthem.com or Fax - 303-831-5833

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.

Provider 

 

  • Credentialed Providers

    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.
    If you have not registered with CAQH, go to the CAQH website to register and obtain a CAQH number. Remember to allow Anthem access to your CAQH online application. You must specify Anthem as an authorized health plan on your CAQH submission. www.caqh.org. Help desk phone: 888 599-1771.


    Provider information













    (behavioral health providers only)

       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
           

    (behavioral health providers only)






    (If yes, STOP and complete the form section titled Non - Credentialed providers)







    Medicare/Medicaid participation



    Primary practice office







    (behavioral health providers only)*





    Payment/Remittance address








    (behavioral health providers only)


    Access and Availability (behavioral health providers only)*
    Life Threatening Emergency  
    Non-Life Threatening Emergency  
    Urgent Needs  
    Routine Needs  

    (behavioral health providers only)*
    Contact/Submitter (person submitting the form)




  • Ancillary providers

    Complete this section if you are this provider type: 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
















    (Please indicate 'all', or list specific counties you will serve)



    Office Hours













    Identification numbers










    Payment/Remittance address








    Licensure



    Governmental Program

    Contact/Submitter (person submitting form)




  • 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















    Provider Type/Specialty









    Medical license



    DEA registration



    Medicare/Medicaid participation



    Internship or residency



    Area(s) of expertise (behavioral health providers only)

    Primary practice information


















    Office Hours























    Practice limitations




    Hospital admitting privileges



    Licensure




    Governmental Program Participation


    Contact/Submitter (person submitting form)




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.

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