Individual Practitioner Enrollment Form

Individual Practitioner Enrollment Form

 

 
1 Credentialing 2 Tax Info 3 Practitioner Info 4 Location 5 Enroll
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Join our Network!

Thank you for your interest in becoming a Blue Cross and Blue Shield of North Carolina (Blue Cross NC) network provider. As a Blue Cross NC provider partner, you will be part of a growing network of physicians, health care professionals and facilities who share our commitment to improving the health and well-being of our members and communities.

The first step is to let us know that you would like to join our network! To join, please have the following information available for each practitioner to be enrolled. 

  • Practitioner License
  • W-9 Form (only for solo practitioners not part of a group)
  • Email the completed W-9 form to ProvRequests@bcbsnc.com
  • Council for Affordable Quality Healthcare (CAQH) ID number

Important Tips:

  1. If you are part of a provider group, complete enrollment for the provider group first. If you have not already enrolled your provider group, please enroll here.
  2. Complete the entire enrollment form and all required data fields noted with an asterisk (*). Missing or inaccurate information delays practitioner’s participation in Blue Cross NC’s network.
  3. Expedite practitioner enrollment by providing accurate and current information.

1.  Credentialing


 

Blue Cross NC has partnered with the Council for Affordable Quality Healthcare (CAQH) to make the application process easier for you. Instead of completing and sending different applications to various payers, you complete one credentialing application that is shared with multiple payers. The result is expedited credentialing processing time, less administrative burden, and more time with patients.

Need more information? To learn more about CAQH and the CAQH Universal Credentialing Data source (UCD), you can read our frequently asked questions for more information.

Start the CAQH Application Process

If you did receive your CAQH ID number, please enter it below.