Administrative updates

*Please note: All entities that share the same NPI must have the same EFT information.*

EFT can be added, removed or updated by completing the Provider Automatic Payment form (PDF). Include a copy of a cancelled check.

Fax to (651) 662-6684 or mail to:
Provider Contract Implementation, R317
PO Box 64560
St. Paul, MN 55164-0560

Complete a Contract Request form (PDF). Check the box “Add an Additional Location” and provide a list of the practitioners that will be providing service at the new location. If additional information is needed for a practitioner, you will be notified. A clinic site visit may be required. Please note: A request for a contract is not a guarantee that you will receive a contract.

The form and practitioner list should be faxed to (651) 662-6684 or mailed to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for the completion of the branch addition process.*

If you are a facility that requires credentialing , please also submit an Facility Initial Provider Credentialing application (PDF) for each type and location. A facility site visit may be required.

Fax to (651) 662-2905 or mail to:
Provider Credentialing, R315
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for the completion of the branch addition process.*

Complete the Tax ID Change form (PDF), checking the appropriate box. A letter explaining the change in ownership or business structure will help ensure accurate changes to your data.

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

If you are a facility that requires credentialing , please submit a Facility Initial Credentialing application (PDF). A clinic site visit or facility site visit may be required.

Fax to (651) 662-2905 or mail to:
Provider Credentialing, R315
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 90 days for completion of this process.*

If the practitioner requires credentialing, submit a MN Uniform Credentialing application (PDF). Fax to (651) 662-2905 or mail to:
Provider Credentialing, R315
PO Box 64560
St. Paul, MN 55164-0560

If the practitioner’s credentialing is current or the practitioner doesn’t require credentialing, complete a Practitioner Addition and Termination form (PDF) or MN Uniform Practitioner Change form (PDF).

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of the practitioner set up process.*

Complete an Individual PCA Data Sheet (PDF).

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of the practitioner set up process.*

Complete the Tax ID Change form (PDF).

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

If you are a facility that requires credentialing , please also submit a Facility Initial Credentialing application (PDF). A clinic site visit or facility site visit may be required.

Fax to (651) 662-2905 or mail to:
Provider Credentialing, R315
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 90 days for completion of the tax change process.*

Complete a Practitioner Addition and Termination form (PDF) or MN Uniform Practitioner Change form (PDF). By checking “yes,” your name will not show up in our provider directories. You may also submit a letter explaining the changes you would like.

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of this process.*

Complete a Practitioner Addition and Termination form (PDF) or MN Uniform Practitioner Change form (PDF).

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for the completion of the practitioner removal process.*

Submit a letter explaining the changes, including the clinic NPI #, new legal business name, DBA name (if applicable) and effective date of change.

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of the change process.*

Complete a Provider Clinic/Branch Closure form (PDF). To ensure proper transition of care for impacted members, please provide at least a 60-day notice of a planned closure.

Fax the form to (651) 662-6684, or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

Please note that if your clinic is changing your tax ID as a result of a merger/buyout, please see the answer to the question: “Add a location as a result of a merger/buyout”.

Complete a MN Uniform Practitioner Change form (PDF) or submit a letter notification of the name change. If the practitioner’s name has not been changed on their license, please provide a copy of the official documentation of the name change.

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of this process.*

**Please note: A request for a contract is not a guarantee that you will receive a contract. Also, you must have an Aware agreement in order to become a Select provider.**

Complete and submit a Contract Request form (PDF), checking the Request Type as “Select (BH or Chiro)” or submit a letter requesting a Select contract.

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 90 days for completion of this process.*

**Please note: A request for a contract is not a guarantee that you will receive a contract. Also, you must hold an Aware agreement before you can request to become a Blue Plus provider.**

Submit a letter requesting to become a Blue Plus Referral or Primary Care Clinic Provider. If you would like to be an in-network provider for our service co-op groups (and you are a specialist provider), you should request a Blue Plus Referral agreement. A clinic site visit may be required.

Fax to (651)662-6684 or mail to:
Network Management, R317
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 90 days for completion of this process*

To receive additional information on registering for electronic transactions, please visit the Availity website.

Complete the Provider Change form (PDF) and submit by fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of the change process.*

An updated NPI can be submitted through Provider Web Self-Service or by completing a Provider Demographic Change form (PDF) for any contracting provider/facility or practitioner already set up on our system. (For new contracting providers/facilities or practitioners, the NPI should be entered on the initial request forms.)

Fax to (651) 662-6684 or mail to:
Provider Data Operations, R316
PO Box 64560
St. Paul, MN 55164-0560

*Please allow up to 60 days for completion of this process.*