Instructions for THIN Third Party Inquiry Enrollment Packet

Complete one set of forms for each site (separate facility)

1.  Print Entire Enrollment package OR Save package to your desktop or documents folder and then follow steps.

2.  Complete site information, user enrollment forms and workstation forms.

- Site Information Form - The Site Contact should be the person we will call if we

need to verify the information (provider numbers, etc.). The Technical Contact is

the person we will call for PC/Network questions.

- User Enrollment Form - List the Provider Name or Group Name, BCBS of TX or

NM provider number(s) and tax id number(s). If you are signing up multiple

physicians, you may use a group number if available. If no group number is

available, please list all physicians and corresponding information.

- Workstation Information Form – Please enter facility or office name.

3. Provider Authorization Letter Sample

- Please enter BCBS of TX or NM provider id and Tax ID information in correct

spaces.

- Enter office contact information in second paragraph along with title and phone

number

- This letter must be printed on your facility or office letterhead.

- Please sign and date letter

4.  Fax all paperwork to Enrollment Administrator at (866) 921-8415 or scan and e-mail to .

5.  For any questions, contact Stacey Smith at (615) 261-1272 or

6.  Billing Agencies: Your clients must complete and sign this paperwork, you cannot complete for them. Please have your client follow steps one through six and return the forms to you to return to Passport.

1. Site Information Form

(Please type or print information clearly)

Site Information

Provider/Site Name:______

Address:______

______

City, State, Zip:______

Site Contact Information

Name:______

Title:______

Phone:______

Fax:______

Email:______

Technical Contact Information

Name:______

Title:______

Phone:______

Fax:______

Email:______

For Internal Use Only:

THIN Third Party Inquiry Site Number:
User ID’s Assigned: / Through
Date:
Notes:

2. User Enrollment Form

Site Name:______

Using the table below, list the providers for whom you want to access information through THIN Third Party Inquiry. If you wish to access information for multiple providers, enter each provider’s individual Blue Cross and Blue Shield Provider Number. Include as many of these pages as needed.

The Blue Shield group or solo provider number is required not the rendering provider number.

All information in the table below is REQUIRED in order to process your enrollment. Enrollments will be returned for missing information.

Provider Name / Blue Cross or Blue Shield Provider Number / Tax ID Number

3. Workstation Information Form

Site Name: ______

How many User ID’s are you requesting? ______1______

We assign one User ID per person using THIN Third Party Inquiry. Sharing User ID’s is not permitted.

PLEASE NOTE:

Your web browser must have 128-bit encryption to connect for internet inquiry.


4. Provider Authorization Sample Letter

THIN

P.O. Box 833905

901 South Central Expressway

Richardson, Texas 75083

Fax - (972) 766-5102

To Whom it May Concern:

Passport Health Communications is our vendor of choice for THIN Third Party Inquiry for Blue Cross Blue Shield of Texas or New Mexico. Therefore, we grant permission to Passport Health Communications to utilize the THIN Third Party Inquiry System to check the status of our patients.

BlueCross BlueShield of Texas or New Mexico provider number (s) Tax ID (s)

______

If you have any questions, you may contact (Name of Person at Provider’s Office), (Title of person) at (XXX-XXX-XXXX) or Stacey Smith at Passport Health Communications, Inc (615) 261-1272.

Sincerely,

______

ÖSignature of provider or Authorized Agent

______

Date

THIN Third Party Inquiry Enrollment Packet – 06/03/03