Get Ma Bcbs Mpc_072516-1k-1-f 2020-2025

Filling out the MA BCBS MPC_072516-1K-1-F form is a crucial step for organizations seeking to participate in the Opioid Treatment Program. This guide will provide you with clear, step-by-step instructions on how to complete the form online, ensuring that you provide all necessary information accurately and efficiently.

Follow the steps to successfully complete the application form.

1. To begin, use the ‘Get Form’ button to retrieve the MA BCBS MPC_072516-1K-1-F form and open it for editing.
2. Fill in organizational information including the provider's legal name, doing business as (DBA) name as it appears on the W-9, the Tax ID number, and National Provider Identifier (NPI) type 2. If applicable, include the Blue Cross non-contracted provider number and Medicare participation details.
3. Input the main business location address, including city, state, zip code, and contact information. Add the management or parent company name and their address if relevant.
4. Identify authorized signatories who will electronically sign the agreement on behalf of the organization. Include their name, title, and email address.
5. Select the Blue Cross products your organization wishes to participate in by checking the appropriate boxes, including options like HMO and Medicare Advantage.
6. List hospitals or physician groups that refer to your organization and provide specific reasons that demonstrate the unique benefits your organization can offer to members.
7. Complete the attestation section by checking the boxes to affirm compliance with claims submission, communications, and reimbursement requirements.
8. Address licensing and malpractice history by answering the relevant questions. Ensure that detailed explanations are attached for any 'yes' responses.
9. Provide service site information, including the site name, address, and accessibility features. Repeat this for each licensed location as applicable.
10. Review and ensure the accuracy of all answers entered into the form. Save any changes made to the document before final submission.
11. After completing the form, you can choose to download, print, or share the document as necessary. Ensure that all required supporting documentation is included before submission.

Complete the MA BCBS MPC_072516-1K-1-F form online today to ensure your application is processed efficiently.