Medicaid (STAR) & CHIP Online Agreement Request Form

Blue Cross and Blue Shield of Texas (BCBSTX) has been selected to provide comprehensive managed care services for the STAR and CHIP programs with the Travis Service Area (Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis, and Williamson counties)

Note: Before you complete & submit your request for the Medicaid (STAR) and CHIP Agreement, you will need to be assigned a BCBSTX Provider Record ID. To get set up, go to Request a BCBSTX Provider Record ID.

 

* Indicates a required field

*Select programs you are interested in:

STAR (Medicaid)
CHIP

*Are you applying as a:

Yes

No -

Primary Care Physician

Yes

No -

Specialty Care Physician/other Professional Provider

Yes

No -

Primary Care Physician and Specialty Care Physician/other Professional Provider

*Practicing Specialty:

*Practicing Sub-Specialty (if applicable):

*Please select the category or categories that best describe(s) your practice:
Category descriptions

Solo Physician
Solo Health Care Professional
Medical Group
Health Care Professional Group
Hospital or Facility Based Provider(s)

Federally Qualified Health Care Group
Rural Health Clinic

*Individual TPI#:

*Group TPI#

(Note: STAR providers must have a current & valid  Medicaid Texas Provider Identifier (TPI) number.  To obtain a TPI # or to update your current TPI #, call Texas Medicaid Healthcare Partnership (TMHP) at 800-925-9126 or go to
TMHP's online enrollment form)

*TAX ID #:

*Type 1 NPI Number required
(Note: If you do not have,
visit the NPI Web site ):

Group Name:

Type 2 NPI Number
(Note: If you do not have,
visit the NPI Web site ):

*Are you a Texas Health Steps (THS) Provider?

Yes  No

If yes, indicate your THS number:

*Is provider indicated above being added to an existing Group Agreement?

Yes  No

Is this request for a new agreement?

Yes   No

Additional TAX ID # (if applicable):

If mid-level provider, list supervising or sponsoring physician's name (if applicable):

*List of back up providers – required for PCPs

Please include the back up provider's NPI:

List Admitting Hospital Privileges (if applicable):

Name to be listed on contract/agreement (if different from above):

In the event we have questions regarding this request, who do we contact?

 

*Contact Name:

*Contact Phone Number:


Ex: ###-###-####

*Contact E-mail Address:

Contact Fax Number:


Ex: ###-###-####

*City & State Where Contact Is Located:

Comments or additional information you would like to provide: