## Add, update or remove provider information ### Add, remove or update electronic funds transfer (EFT) The form to request electronic funds transfer (EFT) changes is only accessible on the Availity Essentials portal. [**Log in**](https://apps.availity.com/availity/web/public.elegant.login) or [**create an account**](https://www.availity.com/Essentials-Portal-Registration) with Availity, then view the Resources tab in Blue Cross Blue Shield Minnesota Payer Spaces. The form is called "NEW-Electronic Funds Transfer (EFT) Form." Users must have access to the Minnesota Region on Availity in order to use the EFT form. To reduce exposure to payment related fraud, Blue Cross will not approve new or updated electronic funds transfer requests received from providers that are not contracted (i.e., non-participating or out of network) with Blue Cross. For more details, view [**QuickPoint QP112-20 Changes to Electronic Funds Transfer Processes**](https://bluecrossmn.widen.net/content/by3fhivaf6/original/final-changes-to-eft-processes-qp112-20.pdf "final-changes-to-eft-processes-qp112-20.pdf") Allow up to **90 days** for completion of this process. *Note: All entities that share the same NPI must have the same EFT information.* ### Add a location as result of a merger/buyout Complete the [**Tax ID Change form**](https://bluecrossmn.widen.net/content/dp4ze0publ/original/provider_tax_id_change_form_july_2020.pdf "provider_tax_id_change_form_july_2020.pdf"). Email the form to: [**Provider.Data@bluecrossmn.com**](mailto:provider.data@bluecrossmn.com) Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **90 days** for completion of this process. ### Add a new/additional location **Note**: If you are not already contracted with Blue Cross Blue Shield of Minnesota under the Tax ID for the new location and are interested in joining our network, visit the[ **Join our Network page**](/providers/network-participation/join-our-network "Join our network"). **If you are a healthcare provider:** - [Fill out the pre-screening provider application form](https://bluecrossmn.quickbase.com/nav/app/bumwwiwnn/action/showpage?pageIdV2=quickbase.com-DashboardGroup-41b98c19-efac-4adc-a131-5148e3cddc6d) - You will then receive an email with the appropriate links to complete necessary form(s) ### Add an additional NPI/UMPI to your practice/facility **Note:** If you are not already contracted with Blue Cross Blue Shield of Minnesota under the Tax ID for the new location and are interested in joining our network, visit the[ Join our Network page](/providers/network-participation/join-our-network "Join our network") If requesting to change the existing contracted NPI to a new NPI/UMPI, see "Update NPI" lower on this page. **If you are a healthcare provider:** - [Fill out the pre-screening provider application form](https://bluecrossmn.quickbase.com/nav/app/bumwwiwnn/action/showpage?pageIdV2=quickbase.com-DashboardGroup-41b98c19-efac-4adc-a131-5148e3cddc6d) - You will then receive an email with the appropriate links to complete necessary form(s) ### Add a new/additional specialty to your existing contracted location If you are not already contracted with Blue Cross Blue Shield of Minnesota under the Tax ID for the new location and are interested in joining our network, visit the[ Join our Network page](/providers/network-participation/join-our-network "Join our network"). **If you are a healthcare provider:** - [Fill out the pre-screening provider application form](https://bluecrossmn.quickbase.com/nav/app/bumwwiwnn/action/showpage?pageIdV2=quickbase.com-DashboardGroup-41b98c19-efac-4adc-a131-5148e3cddc6d) - You will then receive an email with the appropriate links to complete necessary form(s) ### Add a practitioner to your group #### How many practitioners do you have? **Five or fewer practitioners:** When requesting a contract or new location, please submit the [MN Uniform Practitioner Change form](https://bluecrossmn.widen.net/content/ga5x6e8vne/original/mn-uniform-practitioner-change-form.pdf "mn-uniform-practitioner-change-form.pdf") for each practitioner. **Six or more practitioners:** If six or more need to be affiliated with the new location or contract, please fill out the [Multiple practitioner add sheet (xlsx)](https://bluecrossmn.widen.net/content/s8v85pu3ka/original/multiple-practitioner-add-sheet-may-2021-update.xlsx "multiple-practitioner-add-sheet-may-2021-update.xlsx"). #### Where to send your forms? Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **45 days** for completion of this process. ### Add or remove an individual PCA or PCA supervisor to my group Complete an [Individual PCA Data Sheet (Excel)](https://bluecrossmn.widen.net/content/8enqicy4fn/original/individual-pca-data-sheet.xlsx "individual-pca-data-sheet.xlsx"). Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to 45 days for completion of this process. ### Change tax ID Complete the [Tax ID Change form.](https://bluecrossmn.widen.net/content/cuhjudyiok/original/provider-tax-id-change-form.pdf "provider-tax-id-change-form.pdf") Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **90 days** for completion of this process. ### Directory suppress a practitioner or remove a directory suppression Complete and submit the [MN Uniform Practitioner Change form](https://bluecrossmn.widen.net/content/ga5x6e8vne/original/mn-uniform-practitioner-change-form.pdf "mn-uniform-practitioner-change-form.pdf"). Email the form to: [provider.enrollment.and.credentialing@bluecrossmn.com]() Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **45 days** for completion of this process. ### Non-participating setup request form The [Non-participating Setup Request form ](https://bluecrossmn.widen.net/content/15bumc407f/original/non-participating-setup-request-form-january-2022.pdf "non-participating-setup-request-form-january-2022.pdf")is only to be used when requesting to be set up as a non-participating provider. This form is not to be used by contracted providers who are looking to become non participating. Please contact **651-662-5200** or **1-800-262-0820** if you have any questions. Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **90 days** for completion of this process. ### Opt back in to Medicare Please complete this form when a practitioner opts back into Medicare. [Medicare Opt-In Notification](https://bluecrossmn.widen.net/content/6sc6oqdo1b/original/p11ga_16861282-medicare-opt-in.pdf "p11ga_16861282-medicare-opt-in.pdf") Email the form to: [Provider.Data@bluecrossmn.com](mailto:provider.data@bluecrossmn.com) Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **90 days** for completion of this process. ### Remove a practitioner from your group Complete and submit the [MN Uniform Practitioner Change form.](https://bluecrossmn.widen.net/content/ga5x6e8vne/original/mn-uniform-practitioner-change-form.pdf "mn-uniform-practitioner-change-form.pdf") Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 ### Submit a clinic name change For clinics changing their name, please fill out the [Provider Demographic Change form](https://bluecrossmn.widen.net/content/tkhhniragw/original/provider-demographic-change-form.pdf "provider-demographic-change-form.pdf") Email the form to: [Provider.Data@bluecrossmn.com]() Or mail to: Provider Data Operations P.O. Box 982809 El Paso, TX 79998-2809 Please allow up to **45 days** for completion of this process. ### Submit a clinic or location closing Complete a [Provider Clinic/Branch Closure form.](https://bluecrossmn.widen.net/content/6suj4eszoa/original/p11ga_12461576-clinic_branch_closure_form.pdf "p11ga_12461576-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. Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 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.” ### Submit a practitioner name change Complete and submit the [MN Uniform Practitioner Change form.](https://bluecrossmn.widen.net/content/ga5x6e8vne/original/mn-uniform-practitioner-change-form.pdf "mn-uniform-practitioner-change-form.pdf") Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 ### Submit a practitioner's demographics Complete and submit the [MN Uniform Practitioner Change form.](https://bluecrossmn.widen.net/content/ga5x6e8vne/original/mn-uniform-practitioner-change-form.pdf "mn-uniform-practitioner-change-form.pdf") Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 ### Update address or phone number Please complete the [Provider Demographic Change form](https://bluecrossmn.widen.net/content/tkhhniragw/original/provider-demographic-change-form.pdf "provider-demographic-change-form.pdf"). Email the form to: [Provider.Data@bluecrossmn.com]() Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **45 days** for completion of the change process. ### Update NPI An updated NPI can be submitted by completing a [Provider Demographic Change form](https://bluecrossmn.widen.net/content/tkhhniragw/original/provider-demographic-change-form.pdf "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.) Email the form to: Or mail to: Provider Data Operations PO Box 982809 El Paso, TX 79998-2809 Please allow up to **90 days** for completion of this process. ### Questions? Call provider service at **(651) 662-5200** or **1-800-262-0820**. [Provider Frequently Asked Questions](https://bluecrossmn.widen.net/content/aj6k6gpmf4/original/provider-faq.pdf)