Provider Acquisition Form

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will require all providers to complete a Provider Acquisition Form when notifying us of an acquisition or merger effective January 15, 2022. This form allows providers to send notification that they have purchased or merged with another practice. The following documents are required with the form when notifying Blue Cross NC:

• W9 
  
• Any court documents supporting the buyout 

Effective January 15, 2022, this form will be required for any merger or acquisition, however, it is available online now. After January 15th, the Provider Acquisition Form will be the only acceptable form of notification when advising Blue Cross NC of an acquisition or merger. All other forms of notification will be returned to the sender. This change in the process for reporting acquisitions or mergers applies to the following provider types: 

• INN (In network) 
  
• OON (Out of network) 
• Facilities 
• Ancillary Providers 
• All Practices regardless of specialty  

Advance notice pursuant to the notice requirements in a provider’s network participation agreement is required when an acquisition or merger occurs. Please complete this form as soon as possible in advance of an acquisition or merger to allow sufficient time for the request to be processed. Fill out the provider acquisition form for submission.

Review the job aid for mergers and acquisitions including how to complete the form, timing and required documents can be found on our Network Participation page.