Insurances to Contract/Credential

Insurances to Contract/Credential

You will receive a separate link once this form is submitted. Please note our team does NOT work on OWCP (Federal Work Comp)
Name of Clinic*
Clinic Owner*

First NameLast Name
Which state is the provider physically in and treating: *
Name of Other State*
Check Mark the Montana Contracts you would like us to try and obtain*

AllegianceBCBS of MontanaFirst Choice Health NetworkInterwest/Prime HealthHumana (will not allow Mobile providers)Medicaid MTMedicareMedicare - RailroadMountain Health CoopPacific SourceUnited Healthcare/Optum (will not allow Mobile Providers)Triwest (VACCN)Tricare West (Triwest)Other
Check Mark the Pennsylvania Contracts you would like us to try and obtain*

AetnaCignaHighmark BCBSHumana (will not allow Mobile providers)Independence BCBSMedicaid PAMedicareMedicare - RailroadTricare East(Humana Military)United Healthcare/Optum (will not allow Mobile Providers)Veterans CCN Optum (VACCN)Other
Check Mark the Texas Contracts you would like us to try and obtain*

AentaATA/HolistaBCBS of TexasCigna/American Specialty Health (depending on provider type)Cigna Health SpringsCommunity First (only offered in Bexar, Atascosa, Bandera, Comal, Guadalupe, Kendall, Medina, and Wilson Counties)Humana (will not allow Mobile providers)Medicaid TexasMedicareMedicare - RailroadOscarUnited Healthcare/Optum (will not allow Mobile Providers)Triwest (VACCN)Tricare West (Triwest)Other
Check Mark the Washington Contracts you would like us to try and obtain*

AmbetterCigna/American Specialty HealthCoordinated CareFirst Choice Health NetworkHMAHumana (will not allow Mobile providers)Medicaid WAMedicareMedicare - RailroadKaiser PermanentePremeraRegenceUnited Healthcare/Optum (will not allow Mobile Providers)Triwest (VACCN)Tricare West (Triwest)Other
Check Mark the Wyoming Contracts you would like us to try and obtain*

BCBS of WyomingCignaFirst Choice Health NetworkHumana (will not allow Mobile providers)Imagine Health/Wise NetworkMajorisMedicaid WYMedicareMedicare - RailroadUnited Healthcare/Optum (will not allow Mobile Providers)Triwest (VACCN)Tricare West (Triwest)Other
I have thoroughly researched my area and these are the contracts/credentialing that I would like you to add us too and/or I am contracted with these insurances and would like a new provider added to the following:*
If this is a new clinic or new contract/credentialing, both a provider and a group is required to be done separately.

Both need to be provided.
Individual provider to contract.*

First NameLast Name
Individual Providers Email.*
example@example.com
Does this provider live in the same state as your group contract*
Important Information: Group Contracts for New State Additions
Please be advised that if you are adding an individual provider to a new state where your group currently does not have a contract, your group may need to establish a new contract within that specific state.

This is an additional fee because the group itself must be contracted in that state for the individual provider to be successfully credentialed under your group.

Ensuring your group has the appropriate contracts in each state where your providers practice is crucial for seamless credentialing and billing.
Will the Provider be traveling to your state to provide services*
Will the provider only be treating telehealth from their location?*
Will this provider be providing Mobile services at patients homes, practicing at a physical brick/mortar location or both*
Physical practice location the new provider will be working from*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Location your medical records will be stored at*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address you want the mail to go to*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the Mailing address a Post office or other mass mailbox receptacle location? (example UPS store)*
Email that I would like used for a shared Excel Spreadsheet so that I can track the progress of my requests.*
example@example.com
I, blanks* understand that all the contracts that I request may not be available and I understand that I am paying for the labor of Big Sky Billing to attempt to obtain these contracts. Contracting and credentialing are not a guarantee and Big Sky Billing will communicate any knowledge they find out for the requested items. If the insurance states the network is closed I will have to request Big Sky Billing to attempt the request again. I understand that this can only be done every 90-120 days. I also understand that I will not alter or remove any information/pages that Big Sky Billing has filled out on the applications without discussing the matter with the credentialing department. I also understand that Credentialing charge are per NPI/Tax ID combination.
Should be Empty:

Insurances to Contract/Credential

If this is a new clinic or new contract/credentialing, both a provider and a group is required to be done separately.