Complete this form when updating the billing, practice, and contractual notice demographic information for a group or solo provider. Email the completed form(s) to ProviderUpdates@bcbsnc.com or fax to 919-287-8884.
This page will explain the appropriate means to submit a demographic change request to Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Requests can be emailed to ProviderUpdates@bcbsnc.com or faxed to 919-765-4349.
Normal processing time can vary between requests sent to Commercial or Blue Medicare. Average processing time will be from 10–30 business days. Complete provider details (e.g., name, NPI, IRS number, locations, Medicare number) and the effective date for the changes must be provided.
Notice: Incomplete requests will not be accepted for processing. Requests that are incomplete or are missing information will be returned to the sender. The request will need to be resubmitted with complete information to be processed.
- Submit a request on letterhead
- Provide a copy of updated medical license or copy of marriage certificate
- Complete a new contract or amendment for solo providers
- Complete a demographic form or request on letterhead
- Indicate where the address change applies: physical, billing, and / or contract notice addresses
- Include a roster of all practitioners working at a new satellite location
- Submit requests at least 30 days before to the effective date
- Completed a group enrollment application
- Submit an updated W9
- Submit individual enrollment applications for all practitioners who are not currently active in BCBSNC
- Submit current medical license for practitioners who are not currently active in BCBSNC
- Submit a new EFT form for participating groups
- For contracted participating groups:
- Current contract must support specialty of newly added practitioners
- All practitioners must be credentialed (if applicable) to be enrolled
- You may be required to sign a new contract amendment before making these changes, which may affect the effective date
- Submit requests at least 60 days before to the effective date
If you have questions or need assistance, call 800-777-1643, opt 6.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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