Join the NC State Health Plan Network

Clear Pricing Project Contract Request Form

This form is to be completed by providers who are interested in joining the Clear Pricing Project of the NC State Health Plan Network. Please fill in all required fields below. Only submit one web form per provider organization.

Submitter

Practice Information


Contract Level Entity (if different than group practice name) 


Tax ID must match the current information Blue Cross NC has on file in order for a contract request to be processed.   Please use the following format: ##-#######


Facility Information

 

The practice legal name and practitioner roster listed in the contract you receive will match the current PPO data that Blue Cross NC has on file as of May 11, 2021.

Once offered, contracts must be signed within 10 days of receipt or the offer will expire.

Contract effective date will be January 1, 2022.