Blue Shield Practitioner Information Update Guide

This guide details how to update your information with Blue Shield of California and Blue Shield of California Promise Health Plan using the ICF-01 form. It outlines required documentation, specific field instructions, 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 in-person service locations for PCPs and specialists.

Action Steps

• Identify the practitioner needing changes (name, TIN, NPI).
• Complete all applicable fields requiring changes.
• Attach all required documentation as specified.
• Submit the form and documentation via email to BSCProviderinfo@blueshieldca.com.
• For new records, complete form RA-01.
• For network joining info, contact Provider Information and Enrollment.

Key Terms

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

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 in more than six in-person locations.: This is not allowed; the limit is six in-person service locations.
• A specialist wants to be listed in more than ten in-person locations.: This is not allowed; the limit is ten in-person service locations.
• A practitioner provides only telehealth services.: The in-person location limitations do not apply.