Insurances to Contract/Credential

Insurances to Contract/Credential

You will receive a separate link once this form is submitted.
Name of Clinic*
Clinic Owner*

First NameLast Name
Are You Contracting in Montana*

YesNo
Check Mark the Contracts you would like us to try and obtain*

AllegianceBCBS of MontanaFirst Choice Health NetworkInterwest/Prime HealthHumana (will not allow Mobile providers)Medicaid MTMedicareMountain Health CoopPacific SourceUnited Healthcare/Optum (will not allow Mobile Providers)Triwest (VA)/Tricare West
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*
Will the Provider be traveling to your state to provide services*
Will the provider only be treating telehealth from their location?*
Physical practice location the new provider will be working from*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 any information that Big Sky Billing has filled out on the applications without discussing the matter with the credentialing department.
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.