Blue Shield Practitioner Information Update Guide

This guide outlines the process for updating practitioner information with Blue Shield of California and Blue Shield of California Promise Health Plan using the ICF-01 form. It details required documentation and limitations on service locations.

Core Principles

• The ICF-01 form is for updating existing practitioner records.
• New practitioner records require the RA-01 form.
• All changes must be submitted with required documentation.
• Failure to provide documentation results in no action.
• There are limits on the number of in-person service locations for PCPs and specialists.

Action Steps

• Identify the practitioner by name, TIN, and NPI.
• Complete all applicable fields requiring changes.
• Check 'ADD', 'CHANGE', or 'REMOVE' boxes for each field.
• Use the 'Existing' and 'New' columns for changes.
• Attach required documentation (e.g., Articles of Incorporation, W-9).
• Submit the form and documentation via email to BSCProviderinfo@blueshieldca.com.
• Confirm processing of the request with Blue Shield/Blue Shield Promise.

Key Terms

• ICF-01: Individual Practitioner Information Change Form.
• TIN: Tax Identification Number.
• NPI: National Provider Identifier.
• PCP: Primary Care Physician.
• RA-01: Practitioner Record Application form for creating new records.

Real World Examples

• A physician is changing their business structure.: Must submit Articles of Incorporation with the ICF-01 form.
• A practitioner is updating their Tax Identification Number (TIN).: Must submit a signed W-9 or IRS tax document with the ICF-01 form.
• A PCP wants to be listed at 7 in-person locations.: This exceeds the limit of 6 in-person locations and will not be approved.
• A specialist provides only telehealth services at a new location.: This location does not count towards the 10 in-person service location limit.

Timeline

• 01/26: Form T16012-F (ICF-01) version date.