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Professional Fee Schedule Request Online Form

  * Indicates a required field
National Provider Identifier (NPI) Number(s):
* Tax Identification Number:
* Provider Name:
* Primary Specialty:
* Address:
* City/ State/Zip:
* County:
* Provider Office Phone Number:
Ex: ###-###-####
* Contact Name:
* Contact Phone Number:
Ex: ###-###-####
* Contact Fax:
Ex: ###-###-####
* Contact E-mail:

* Product:

 BlueChoiceSM

      Facility Non - Facility

 Blue Advantage HMOSM

      Facility Non - Facility

 Blue Medicare Advantage (PPO)SM

      Facility Non - Facility

 Blue Medicare Advantage (HMO)SM

      Facility Non - Facility

 Blue EssentialsSM

      Facility Non - Facility

 Blue PremierSM Texas

      Facility Non - Facility

 ParPlan

      Facility Non - Facility

 Blue High Performance NetworkSM (BlueHPN)SM

      Facility  Non - Facility

* Fee Schedule Effective Date :
i.e. September 1, 2021