Use the individual checklist, group checklist or in state, out of network checklist to find all the forms and documentation needed for each practice type and network.

• Appendix D - For groups participating with BlueChoice.
• Application for Clinic/Group/Institution/Location to File Claims or to Change Employer Identification Number (EIN)
• Authorization to Bill
• Change of Address Form
• Clinical Laboratory Improvement Amendment (CLIA) Certification Verification Form
• Doing Business As (DBA) Name Change Form
• 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 - To receive ERAs through our EDI Gateway (EDIG), please complete one of these forms. Return the completed EDIG ERA Enrollment form to edi.services@bcbssc.com. The enrollment takes approximately one week. 
• Electronic Funds Transfer (EFT) Application and Terms and Conditions - 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
• NPI Update Form
• 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. 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.
  Reminder:  If you are adding a practitioner to your group/locations, please refrain from submitting claims until you have received 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
• Virtual Care Services Application - Complete this form for your practice to apply for participation with telemedicine and/or telehealth services. Email the completed application with supporting documentation to VirtualCare@bcbssc.com. You can also view our frequently asked questions for more information.

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