Provider Information Changes
You must notify Blue Cross of Idaho Dental Services with written documentation of the following changes via email, fax or mail. For your convenience, use the Dentist Profile form to submit the following changes:
- Change of address
- Change of phone and/or fax number
- Change of clinic or provider name
- Provider leaving practice
Contact the Dental Provider Relations Representative to determine the appropriate paperwork needed if you have:
- Providers joining your practice: Dentist Profile form, Copy of License, DEA Certificate, Malpractice Insurance Face Sheet
- Additional Location: Dentist Profile form
- Change in ownership or tax identification number of a solo practice or clinic: include a copy of the updated W-9 and the Dentist Profile form
If your tax identification change represents a change of ownership, your contracts with Blue Cross of Idaho may not be valid. Please contact the Dental Provider Relations Representative prior to ownership changes to assure your contracting status remains in place.
Include the effective date of all changes (we will not make retroactive changes but we can process future effective dates). When the request for change specifies a past date, the change will take effect on the date we enter the information into our system and may reflect a past date. If the change is in the future, the future date is the effective date. We will set up provider information in our systems within 10 business days of receiving a request for change.