Some insurers have different formularies that are covered under different plansand they indicate which formulary on members' ID cards. Declaration of Disability for Over Age Dependent Children (C3674). Once you create a new CDPHP member account, log in and click. eviCore Medical Oncology Drug List. This will have your new member ID number. Please carefully read and follow the instructions contained within the individual form for submission. * Effective date New email address New phone number New fax number New address line 1 (PDF, 551KB), SubscriberChangeRequest(Chinese) Listed below, by subject-matter category, are the forms available on this site. The employee'sprimary care physicianmust complete this form and submit it to Blue Shield. Delta Dental PPO participation packet request. (PDF, 248 KB) 3. If the change applies to multiple providers in a group practice, include a roster of all providers, NPIs, and specialties. 2022Highmark Blue Shield of Northeastern New Yorkis a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. The My CDPHP app will let you access your account information 24/7 all in the palm of your hand. Practitioner information change . Check an employee's coverage. Ability to see a doctor online. (PDF, 347 KB) Authorization of Release of PHI(Hindi) Use AHC11234, Practitioner Request, to register practitioners and create . (PDF, 1.4 MB), ContinuityofCareBrochure(English) Copyright 2022 DOH. If you need help finding what you're looking for, please visit our Site Map, use the search above, or you can contact us directly for assistance. Authorization of Release of PHI(Vietnamese) In addition, employees must complete a Subscriber Statement of Disability and a Notice of Total and Permanent Disability. (PDF, 111 KB). Attestation form for Physician Assistant/CRNA/Registered Nurse First Assist (RNFA) that have a collaborating agreement with a Supervising Physician. Indirect Cost Rate Forms. You will have to enter your new member ID number and use a completely new password. In order to streamline our provider information management system and comply with the No Surprises Act (NSA) effective January 1, 2022, new provider change forms are now available. To view a PDF document, your computer must have Adobe Reader installed. Continuous orthodontic coverage form for DeltaCare USA. *A.2 Practice National Provider Identifier (NPI) Number Enter the practice NPI number. Request for Continuity of Care Services(Hindi) Electronic Enrollment and Maintenance (101+), Manage Your Small Business Account Online (1-100), RequestforContinuityofCareServices(English), Request for Continuity of Care Services(Spanish), Request for Continuity of Care Services(Chinese), Request for Continuity of Care Services(Vietnamese), Request for Continuity of Care Services(Hindi), Request for Continuity of Care Services(Korean), Conversion to Individual Coverage Request, DeclarationofDisabilityforOverAgeDependentChildren, Attending Physicial Statement of Disability, Medicare Prescription Drug Plan Disenrollment Opt-Out Form, Medicare Prescription Drug Plan Disenrollment Opt-Out Form with remaining creditable Rx Coverage, ConversiontoIndividualPolicyfromGroupLifeInsurance, LifeInsuranceBeneficiaryChangeRequest, Authorization of Release of PHI(English), Authorization of Release of PHI(Spanish), Authorization of Release of PHI (Chinese), Authorization of Release of PHI(Vietnamese). Our member services team is available to help with any questions you may have, so feel free to give them a call at the number on your CDPHP member ID card for extra support. Once your old plan ends, you will not be able to redeem any earned Life Points from that plan. If approved, the projects plans must reflect the change and the change must be implemented. (PDF, 487KB), LifeInsuranceBeneficiaryChangeRequest s (BA) and their associated relationships. Locum tenens provider form. When submitting a provider inquiry for review, please submit all materials as indicated within the form. Address change form. Has my registration been processed yet? Capital District Physicians Health Plan, Inc. 500 Patroon Creek Blvd., Albany, New York 12206, *NCQAs Private Health Plan Ratings 2019-2020. Please Note: If you only will Order/Prescribe/Refer/Attend see Option 2 Below Option 2 Nurse Practitioner - Order/Prescribe/Refer/Attend ONLY Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. (PDF, 1.2MB), SubscriberChangeRequest(Spanish) For more information on star ratings, visit www.medicare.gov. Please keep in mind this is public information. 4. You must include a picture of the legal document that changed your name. Access it by clicking on the top right corner of the homepage where it says "Hi, [your name]" and then click Release of Health Information; Check your Prior Authorizations APPENDICES - Provider Manual. Bennett has held the position since 2008 after serving more than 10 years as chair, vice chair, and board member for CDPHP. (ENTER BILLING CMAP ID NUMBERS ONLY) (PDF, 1.28 MB) It will enable them to fully document their request, the rationale for it and the likely effect on the project, should it be approved. Forms From prior authorization and provider change forms to claim adjustments, MVP offers a complete toolkit of resources for our providers. Matrix Medical Network is a leading clinical services organization that supports the needs of diverse and vulnerable populations, working with millions of individuals across the country to assess and help them manage their health risks through a network of approximately 5,000 clinicians. Small Businesses (1-100) | Large Groups (101+) | Continuity of Care | Miscellaneous | Specialty Benefits. Prescription coverage starting. (PDF, 43KB). Completing the Form. Disclosure of Ownership and Control Form - Practitioner; Provider Enrollment Application Checklist; New Provider Enrollment and Disclosure Form; Primary Care Physician (PCP) Change Form This is a form that providers will supply to the patient/member when they are changing their PCP. Access it by clicking on the top right corner of the homepage where it says Hi, [your name] and then click. During his tenure, CDPHP has been ranked among the top-performing health plans in New York and the nation, most recently named #1 in Customer Satisfaction in the J.D. (PDF, 691KB), Use this form to submit a monthly summary of employee changes to your existing members, such as adding or deleting dependents. All Forms & Guides. (PDF, 1.23 MB) Power 2019 award information, visit jdpower.com/awards, Select or confirm your primary care provider (PCP), You already have CDPHP through your job, but youre about to start a job with a new company that also offers CDPHP health insurance for employees, You currently have health care coverage through your job, but are now eligible for Medicare, You have Medicaid, but will soon be getting health insurance through a new job, You have health insurance through a job, but youll soon be going on Medicaid. Submit the important Release of Health Information form. Have the form completed correctly before sending it by mail or fax to the appropriate address below. All Rights Reserved. Utilization Management Master Drug List. Make a change request today . Request to Resolve Provider Negative Balance The online MFA process uses your login credentials plus an additional source (email, phone/voice, text, or authenticator app) for supporting "evidence" of your identity before granting access to your member account. While registering, feel free to use the same email address that was used with your last account. 2022 California Individual ACA Plan Change Form. Genetic Disease Screening Program. Information Change Form - Step 1. TOP.. Partnership and Innovation for Healthcare 55 Dodge Road Getzville, NY 14068 716-831-2700. Food and Drug. Use this form for employees who have held group coverage for three or more consecutive months and are eligible to transfer to an individual conversion plan when they retire, leave the job or become ineligible for group coverage. Security | Privacy | Terms of Use | Notice of Non-Discrimination and Translation Assistance. Use this form for new and established enrollees to continue care with a current healthcare provider who is leaving the Blue Shield provider network. Online Only. Complete and submit this form to request a name change for your license. *A.1Practice Name Enter the name of the practice that is requesting the change(s) contained in this form. Same-day appointments are often available, you can search for real-time availability of Nurse Practitioners who accept CDPHP insurance and make an appointment online. (PDF, 456 KB), Medicare Prescription Drug Plan Disenrollment Opt-Out Form Request for New Billing Practice (Assignment Account), Addition Request to Existing Billing Practice (Assignment Account), Nurse Practitioner Agreement/Acknowledgement, HMNY Recredentialing Application for Facility and Ancillary Providers, Statins Therapy for Patients with Cardiovascular Disease (SPC), Kidney Health Evaluation for Patients With Diabetes (KED), Hemoglobin A1c for Patients With Diabetes (HBD), Eye Exam for Patients With Diabetes (EED), Behavioral Health Clinical Criteria Set Request Form, Behavioral Health Practitioner Questionnaire, Behavioral Health Out-of-Plan Referral Review Request Form, Chemical Dependency Outpatient Treatment Review (OTR) Form, Mental Health Outpatient Treatment Review (OTR) Form, Outpatient Applied Behavioral Analysis Treatment Report, Transcranial Magnetic Stimulation (TMS) Request Form, Durable Medical Equipment Preauthorization Form, Injectable Medication Prior Approval Medical Necessity Form, Preauthorization Form: Outpatient Services, Preauthorization/Non-Formulary Medication Request Form, Disclosure of Ownership and Control Form - Facility, Disclosure of Ownership and Control Form - Practitioner, Provider Enrollment Application Checklist, New Provider Enrollment and Disclosure Form, Request to Resolve Provider Negative Balance, Notice of Non-Discrimination and Translation Assistance. Make sure your contact information is current with us. Provider Information Management forms are used to maintain provider accounts as well as begin the process to join Highmark's networks for new practitioners and offices. You can fill out one form per provider in your practice. as low as a penny a pill. Please use these forms to ensure faster processing time. Medical Exception Request Form. Use the Employer Portal to: Add members and terminate members. PLEASE TAKE NOTE: We recently removed many of the maintenance forms from this page. Fill in the required fields (these are yellow-colored). (PDF, 448 KB), Attending Physicial Statement of Disability Power Member Health Plan Study 2021. Please select all fields that apply. The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself. We recommend using our online version where it is available. (PDF, 1.33 MB) But by implementing this Change Request Form and process you can control and monitor change substantially improving your chance of project success. Access CDPHP Providers' page to view important forms & documents, helpful tips on supporting your CDPHP patients, and the latest formularies. Clinical Exception Request for Brand Name and Non-preferred Drugs. CDPHP reserves the right to review and audit . (previously the Provider Demographic Change Form), Participating Providers should utilize this electronic form to update name, address, phone number, email or web address, and specialty type for a practitioner or group. (CP1020). CareContinuum Medical Benefit Management Program. If youd like to start one. Learn more about continuity of care services for new and existing members of a Blue Shield of California plan. Prescription Costs You can make changes to your: Name Pharmacy Prior Authorization. Dentist directory update form. Please continue to bill claims as previously submitted until you receive confirmation that this form has been processed. This form must be updated as a condition of practice. Specialty Drugs. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. Use this form to update billing address or contact information. Communicable Disease Control (For Use by Public Health Officials Only) Environmental Management. Youll also want to take the personal health assessment (PHA) so you can start earning Life Points! Update your information now Action: Revocation. Subscriber Change Request (English) (PDF, 1.3 MB) Subscriber Change Request (Spanish) 1. Authorization of Release of PHI(English) Form 225, Form 363, Form 510 (Form 224 unavailable in PDF) Check the Status of My Application. When this happens, your plan information basically resets and you are a new member in our system. The change request form is arguably the most important document in the change control process. Protected Member Addresses (PMA) are used when you would like your plan materials to go to a different, and protected, address. Execute Cdphp Prior Auth Form within a few clicks by using the guidelines below: Select the document template you will need from the collection of legal form samples. CDPHP requires MFA as an extra security check to make sure your information stays safe. This form should be used to enumerate Advance Practice Providers (APPs) in Highmark's reimbursement systems. CA Employer Application for Group Benefits (126+ lives) (111 KB ) CA Employer Application for Group Benefits (51-250 lives) (60 KB ) CA Group Change Form (517 KB) This is a form that providers will supply to the patient/member when they are changing their PCP. Use this form for making multiple subscriber-level plan changes at renewal. Enrolled Practitioners SEARCH (including OPRA), National Diabetes Prevention Program (NDPP), Edit/Error Knowledge Base (EEKB) Search Tool, Certification Statement/Instructions for Existing ETINs, Default Electronic Transmitter Identification Number (ETIN), Electronic Funds Transfer (EFT) Authorization Form, Electronic or PDF Remittance Advice Request, Provider Electronic/Paper Transmitter Identification Number (ETIN), Remittance Consent and Copy Request Forms, Service Bureau Electronic/Paper Transmitter Identification Number (ETIN). You can download the program by clicking the button below: Please open and type your information into the form, then print, sign and mail in to eMedNY. Option 1 Nurse Practitioner - Individual Billing Medicaid If you Do/Will Provide Medical Services and Bill Medicaid Click here for the Enrollment Form and Instructions. Be sure to throw away your old member ID card and let your doctors know your new ID number during your next visit. Please use the CDPHP Provider Data Management Form to update your information online. Facility and Ancillary Providers who have recently received a Facility and Ancillary Recredentialing Announcement letter should use this application to begin the Recredentialing process. Forgot Password. Authorization of Release of PHI (Chinese) Coverage for all your. You will need Adobe Reader to complete the fillable form. Use this form for enrolled dependent children who would normally lose their eligibility under this plan solely because of age, but who are incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness or condition. (PDF, 17 KB), Medicare Prescription Drug Plan Disenrollment Opt-Out Form with remaining creditable Rx Coverage 2022 Legacy Application Change Form for CA. Prescription Program. Cal-EIS Fellowship. Hospice Agency Change of Location Application Packet. Cardiology; Change Request Form Hi All, This is my first post, hoping you can help - My objective is for a form to be created for IT Changes that users can complete and then a select audience is notified when a form has been submitted, also the forms will need to be stored so we they can be reviewed if need in the future. reserved. Fax or mail this form back to: CDPHP Pharmacy Department, 500 Patroon Creek Blvd., Albany, New York 12206-1057 Phone: (518) 641-3784 Fax: (518) 641-3208 . As part of our continued effort to provide a high quality user experience while also ensuring the integrity of the information of those that we service is protected . A Hospice means "a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of . View billing information and pay a bill. Forgot Username Continuity of Care Brochure(Hindi) (PDF, 544KB), SubscriberChangeRequest(Spanish) Continuity of Care Brochure(Vietnamese) *A.3 List all Connecticut Medical Assistance Program (Group CMAP) numbers for the change(s) request. Fax or mail this form back to: CDPHP Pharmacy Department, 500 Patroon Creek Blvd., Albany, New York 12206-1057 Phone: (518) 641-3784 Fax: (518) 641-3208 . CDPHP requires MFA as an extra security check to make sure your information stays safe. Please use this form when needing to update practitioner's affiliation to existing billing practice (assignment account). (A16170). (PDP00038), Medicare Prescription Drug Plan Disenrollment Opt-Out Form Victoria joined CDPHP in 2018 as an intern in Product Innovation while she was completing her MBA and has served as Operational Support Services Customer Insight Analyst since 2019. Name Change Request Form. for such additional documentation or additional necessary information may result in the request being denied. Use this form to file for an extension of benefits. ConversiontoIndividualPolicyfromGroupLifeInsurance Without proper change control, projects usually encounter scope creep, slippage and substantial delays. (PDF, 45 KB), Subscriber Statement of Disability Online Only. Thank you for helping us ensure that our records are current. (PDF, 1.32 MB), Conversion to Individual Coverage Request Authorization form for Blue Shield of California and/or Blue Shield of California Life & Health Insurance Company to Disclose Personal Health Information to a Third Party. Use this form when completing Diabetic Retinal Exam Referrals. If youve had CDPHP health coverage in the past and now youre switching to a new type of plan with CDPHP, there are a handful of things youll want to take care of as you change plans. The online MFA process uses your login credentials plus an additional source (email, phone/voice, text, or authenticator app) for supporting "evidence" of your identity before granting access to your account. Request an additional receipt for a previously submitted Renewal Application. On average, patients who use Zocdoc can search for a Nurse Practitioner who takes CDPHP insurance, book an appointment, and see the Nurse Practitioner within 24 hours. This Change Request process and supporting template, guidelines, checklist and tips helps your team document and manage requests for change both easily and effectively. Employees should complete this form if they or their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. Click on the Get form button to open it and begin editing. (C675-1) This form should be used to report changes to employees' personal information or any type of coverage changes, such as adding or deleting dependents. To check 1199SEIU patient eligibility, benefit and claim status information, please visit our provider portal at www.NaviNet.net, or call (888) 819-1199 to be connected to our 24-hour automated claims and eligibility system. CAQH Provider ID:* The provider is required to register an account with the Council for Affordable Quality Healthcare (CAQH) prior to applying to CDPHP. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. New Applications. A licensee shall notify the board of a name change within 30 days of the change. Your old CDPHP member account will expire 90 days after your previous plans termination date. This enhancement alleviates problems related to legibility of the information entered on the forms. Simple Change Request Form Often during projects requests for changing the initial project scope occurs. The site is updated regularly to meet the ever-growing needs of the New York State provider community. Pharmacy/Medication Prior Authorization Request Form Individualized Service Recommendation: PROS Admission Request Psychological and Neuropsychological Testing Request Preauthorization for Medical Services Request Form (Utilization Review) Student Out-of-Area Prior Authorization Form Synagis Seasonal Respiratory Syncytial Virus Enrollment Form Please use this form when you need to create a billing account for your practice. Continuity of Care Brochure(Spanish) Forms. (PDF, 1.22 MB) screenings at no cost to you. (PDF, 121 KB) In addition, Victoria sits on multiple cross functional teams to help conduct customer intimate initiatives. A Change Request is raised when any stakeholder believes that a change is needed to the project. 2022 Individual Enrollment Application for California. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. California Physicians Service DBA Blue Shield of California is an independent member of the Blue Childhood Lead Poisoning Prevention. Easy to use, just fill-in the blanks Flexible, add or delete content Illustrative example included Every year, Medicare evaluates plans based on a 5-star rating system. Find Contact Information; Request a Consultation with a Clinical Peer Reviewer; Request an Appeal or Reconsideration; Receive Technical Web Support; Podcasts; Solutions. (PDF, 154 KB). (PDF, 733 KB), SubscriberChangeRequest(Vietnamese) Direct deposit/EFT authorization. Simply log in to your current CDPHP member account online and redeem them through CafWell before your new plan begins. Download and print helpful material for your office. Here are some examples of when you might be switching the type of plan youre on: Although youre already a CDPHP member, youre technically switching to a new plan. business arrangement. Attending Physician Statement of Disability. Individual practitioners who are already credentialed with CDPHP and are requesting an address/tax ID change or other demographic update should complete the Practitioner Information Change Request Form (You must download or right click and select "Save link as" to save this form to your Documents or Desktop before using. It's easy! DeltaCare USA participation packet request. (PDF, 1.65 MB) AIDS. Authorization of Release of PHI(Spanish) In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age. As a reminder, participating providers may not under any circumstances bill a Fidelis Care member (except for copayments or coinsurance for applicable lines of business for any services rendered under an agreement with Fidelis Care) unless the provider has advised the member, prior to initiating service, that the service is not covered by Fidelis Care for that specific member's product line of . Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. You'll be able to find helpful manuals and reference material, and get answers to questions about New York Medicaid. *If you are aMedicaidorChild Health Plusmember, pleaselogin here. * If you do not have a CASAC, CASAC Trainee, CPP/CPS or CPGC number, you may report your changes by submitting an email to [email protected]oasas.ny.gov. Practitioner Information Practitioner Signature: . Live, local reps to answer. This form should be used to report changes to employees' personal information or any type of coverage changes, such as adding or deleting dependents. Appendix I: Authorization Grids Appendix II: Pharmacy Services Appendix III: Coverage of Vaccines for Medicaid and Child Health Plus Members (Effective December 1, 2020) Coverage of Vaccines for Metal-Level Product and Essential Plan Members (Effective December 1, 2020). A Change Request is raised when any stakeholder believes that a change is needed to the project. There are a couple of items that carry over with you when you switch to different types of plans through CDPHP. (PDF, 126 KB), DeclarationofDisabilityforOverAgeDependentChildren At Anthem, we're committed to providing you with the tools you need to deliver quality care to our members.

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