Welcome to Anthem Blue Cross and Blue Shield

New Provider Application Form

This New Provider Application Form should be used by Nevada ancillary providers to apply for participation, or to add a provider to an existing group, with Anthem Blue Cross and Blue Shield.

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, medical specialty pharmacy.

An IRS W-9 form must be submitted through email separately to enterpriseancillary@anthem.com

What Happens Next?

After processing your application, you will receive correspondence from Anthem's Provider Engagement and Contracting department to notify you of the outcome.

You can begin seeing Anthem members as an in-network Provider after you receive notification of approval from Anthem, 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

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 What type of provider are you?
Corporate name as it appears on W-9
Company/DBA name (if different from above)
Address line 1
Address line 2
City
State
County
Zip code
Office phone number
Office fax number
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 Nevada?
Do you do business in Nevada?
What counties will you serve? (Please indicate 'all', or list specific counties you will serve)
24x7 phone coverage at this location?
Does this office provide handicapped accessibility?
Please list any non-English languages spoken by office personnel.

Office Hours Monday Start Time
Monday End Time
Tuesday Start Time
Tuesday End Time
Wednesday Start Time
Wednesday End Time
Thursday Start Time
Thursday End Time
Friday Start Time
Friday End Time
Saturday Start Time
Saturday End Time
Sunday Start Time
Sunday End Time

Identification numbers Tax Identification Number (TIN)
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

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 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*

By clicking on the tab marked "SUBMIT" below, I agree as a condition of practicing in Nevada, 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.

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Welcome to Anthem Blue Cross and Blue Shield

New Provider Application Form

Provider

Ancillary providers