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Independence would like to remind you about the importance of submitting
changes to your provider information in a timely manner. Keeping your provider
information current and up-to-date helps to ensure prompt payment of claims,
delivery of critical communications, seamless recredentialing, and accurate
listings in our provider directories. Per your Independence Professional
Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider
Agreement (Agreement), you are required to notify Independence whenever key
practice information changes.
Professional providers
As outlined in the Administrative Procedures section of the Provider
Manual for Participating Professional Providers (Provider Manual),
Independence requires 30 days advanced notice to process most updates, with the
exceptions noted below:
- 30-day notice. Independence requires 30 days advanced notice for the
following changes/updates to your practice information:
- updates to address, office hours, total hours, phone number, or fax
number;
- changes in selection of capitated providers (HMO primary care
physicians [PCP] only);
- addition of new providers to your group (either newly credentialed
or participating);
- changes to hospital affiliation;
- changes that affect availability to patients (e.g., opening your
panel to new patients).
- 60-day notice. Independence requires 60 days advanced written notice
for closure of a PCP practice or panel to additional patients.
- 90-day notice. Independence requires 90 days advanced written notice
for resignation and/or termination from our network.
Note: Independence will not be responsible for changes not processed due
to lack of proper notice.
Submitting updates and/or changes*
Professional providers can use the Provider Change Form to quickly
and easily submit most of the changes to their basic practice information.
Please be sure to print clearly, provide complete information, and attach
additional documentation as necessary. Mail your completed Provider Change
Form to:
Independence Blue Cross
Attn: Network
Administration
P.O. Box 41431
Philadelphia, PA 19101-1431
You can also fax the completed form to Network Administration at
215-988-6080. Please be sure to keep a confirmation of your fax.
Note: The Provider Change Form cannot be used if you are
closing your practice or terminating from the network. Refer to
"Resignation/termination from the Independence network" in the Administrative
Procedures section of the Provider Manual for more information regarding
policies and procedures for resigning or terminating from the network.
Facility and ancillary providers
As outlined in the Administrative Procedures section of the Hospital
Manual for Participating Hospitals, Ancillary Facilities, and Ancillary
Providers, Independence requires 30 days advanced notice to process the
following changes to your information:
- updates to address, phone number, or fax number;
- adding or removing providers from your panels (either newly credentialed or
participating).
Note: Independence will not be responsible for changes not processed due
to lack of proper notice.
Submitting updates and/or changes
Per your Agreement, all changes must be submitted in writing to our
contracting and legal departments at the following addresses:
Independence Blue Cross
Attn: Senior Vice
President, Provider Networks and Value-Based Solutions
1901 Market Street, 27th Floor
Philadelphia, PA 19103
Independence Blue Cross
Attn: Deputy General Counsel, Managed Care
1901 Market Street, 43rd Floor
Philadelphia, PA 19103
Authorizing signature and W-9 Forms
Certain updates result in a change on your W-9 Form, including changes to a
provider's name, tax ID number, billing vendor or "pay to" address, or
ownership. The following requirements apply when making these types of updates:
- For professional providers: A physician or office manager signature
is required.
- For facility and ancillary providers: Written notification on
company letterhead is required.
An updated copy of your W-9 Form reflecting these changes must also be included
to ensure that we provide you with a correct 1099 Form for your tax purposes.
If you do not submit a copy of your new W-9 Form, your change will not be
processed.
If you have any questions about updating your provider information, please
contact your Network Coordinator.
*Behavioral health providers contracted with Magellan
Healthcare, Inc., an independent company, must submit any changes to their
practice information to Magellan via their online Provider Data Change form at
www.MagellanHealth.com/provider by contacting their Network
Management Specialist at 1-800-866-4108 for
assistance.
Magellan Healthcare, Inc., an independent company, manages
mental health and substance abuse benefits for most Independence Blue Cross
members.
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