New Org Admin

Organization Enrollment

This form should be completed only by an officer or owner of the practice or organization who is authorized to bind a contract with the plan.
Organization Signatory
Provider Verification
Additional Verification
Organization Administrators
Review & Submit
Organization Signatory Information Need Help? View PEAR Portal Inquiry Form
First Name 
    
Last Name 
    
Job Title 
    
Email Address 
    
Confirm Email Address 
    
Phone Number 
 Ext. (optional) 
  

By clicking the  box below, I attest that I have been authorized by all participating providers that participate in the group  practice with the Tax Identification Numbers (TIN) identified in the Provider Engagement Analytics and Reporting (PEAR) portal enrollment process ("Group Practice") to designate the Organization Administrator for Group Practice.

 

ACCEPT the Provider Organization Signatory Attestation

 
Organization Type:  Are you requesting PEAR access for one tax identification number or multiple tax identification numbers? 

One tax identification number   Multiple tax identification numbers
  
Organization Name   
  
   
  
Group/Facility NPI   
Claims
Please enter two claims that meet the below criteria to verify your organization:
1. Billed with your organization's taxpayer identification number.
2. The claims were paid at least 2 weeks prior to the current date.
3. Claims must be for two unique members.
4. Cannot be a BlueCard claim for out-of-area membership.
  Claim Number   Date Of Service  Total Billed Charges   
1  
2  
Organization Administrator No. 1
  Same as Organization Signatory?
First Name 
    
Last Name 
    
Job Title 
    
Email Address 
    
Confirm Email Address 
    
Phone Number 
 Ext. (optional) 
  
 
Organization Administrator No. 2
  Prefer NOT to have a second Organization Administrator?
First Name 
    
Last Name 
    
Job Title 
    
Email Address 
    
Confirm Email Address 
    
Phone Number 
 Extension