1. HealthCare Administrative Solutions, Inc.
Participating Health Plan
Contracting and Enrollment
Required Documents Listing
April 2018

2. Important Notice
As a service to providers, HCAS has created this document based on information provided to HCAS by each health plan.
Note: Health plan specific requirements are subject to change and may be updated from time to time.  If a provider has any questions regarding a health plan’s specific requirements, please contact that health plan directly for further details.

3. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting and Enrollment– Blue Cross Blue Shield of Massachusetts
Download the appropriate forms at – click on Become a BCBSMA Provider.
To learn more about the credentialing process and required documentation go to
Blue Cross Blue Shield of Massachusetts
Department Name: Network Management and Credentialing Services
Phone:
Fax:

4. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Boston Medical Center HealthNet Plan
Letter of Interest R
Participating Provider Agreement
W-9 Form
BMCHP Provider Data Form (one per provider)
Available on
HCAS Provider Enrollment Form
BMCHP Abbreviated Credentialing Form (Hospital Based & Locum Tenems) CR
Boston Medical Center HealthNet Plan
Mailing Address:
529 Main Street, Suite 500
Charlestown, MA 02129
Phone:
Fax:
R= Required
CR = Conditionally Required
O=Optional

5. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Fallon Health
Provider Contract R
Provider Participation Agreement
W-9 Form
Enrollment Form
Attestation for Nurse Practitioner Provider Status CR
Attestation for Physician Assistant Provider Status
Fallon Health
Mailing Address:
One Chestnut Place
10 Chestnut St.
Worcester, MA
Fax:
Provider Services: ,
Option 4
R= Required
CR = Conditionally Required
O=Optional

6. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Harvard Pilgrim Health Care
Provider Contract or Provider Participation Agreement (Joinder) R
W-9 Form
Enrollment and Billing Information
Harvard Pilgrim Health Care
Mailing Address:
Attn: Provider Processing Center
1600 Crown Colony Drive
Quincy, MA
Fax:
Provider Service Center:
R= Required
CR = Conditionally Required
O=Optional

7. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Health New England
Provider Participation Agreement R
W-9 Form
PHO assignment, if applicable
HCAS Provider Enrollment Form including demographic information, tax id number and payment mailing address
Health New England
Mailing Address:
Provider Contracting
One Monarch Place, Suite 1500
Springfield, MA 01144
Fax:
R= Required
CR = Conditionally Required
O=Optional

8. Contracting and Enrollment - Initials
Note that Allways Health Partners contracts with most Providers at the Group Level. The Group is responsible for submitting the contracting elements below. The Group must submit a Data Sheet when individual providers need to be added to the group.
Allways Health Partners
Mailing Address:
Provider Network Management
399 Revolution Drive
Somerville, MA 02145
Fax:
Provider Service Center:
Phone:
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Allways Health Partners
Formerly known as Neighborhood Health Plan
Vendor Contract R
Practice Profile
W-9 Form
Data Sheet for Individual Providers
Enrollment Form
R= Required
CR = Conditionally Required
O=Optional

9. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments - Tufts Health Plan
Appropriate Provider Contract documents R
Enrollment Form or enrollment section of IMA
W-9 Form
Tufts Health Plan
Mailing Address:
Credentialing Department
705 Mt Auburn Street, 6th Floor
Watertown, MA 02472
Fax:
Your Credentialing Contact
Phone:
R= Required
CR = Conditionally Required
O=Optional

10. Contracting and Enrollment - Initials
Plan Information
(direct to plan)
Contracting & Enrollment Attachments – Tufts Health Public Plans
Enrollment Form R
Provider Contract
W-9 Form
Letter of Interest
Tufts Health Public Plans
Mailing Address:
Tufts Health Plan Attn: Contracting Department P.O. Box 9194 Watertown, MA
Fax:
Provider contracting service:
R= Required
CR = Conditionally Required
O=Optional