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Independence would like to remind you that, per your Independence
Professional Provider Agreement and/or Hospital, Ancillary Facility, or
Ancillary Provider Agreement (Agreement), you are required to notify
Independence whenever key provider demographic information changes. Submitting
changes in a timely manner helps to ensure prompt payment of claims, delivery
of critical communications, seamless recredentialing, and accurate listings in
our provider directories.
Professional providers*
Independence requires at least 30 days advanced notice to process most
updates as long as the information submitted is accurate. For a complete
outline of the advanced notice time frames that Independence requires to
process most updates, refer to the Administrative Procedures section of the
Provider Manual for Participating Professional Providers (Provider
Manual). Most of the changes to basic practice information can be quickly
submitted using the Provider Change Form.
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 at least 30 days advanced written notice
to process changes to your information as long as the information submitted is
accurate.
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
Updates resulting in a change on your W-9 Form (e.g., changes to a
provider's name, tax ID number, billing vendor or "pay to" address, or
ownership) require the following signatures:
- For professional providers: A signature from a legally authorized
representative (e.g., head physician of the practice, practice administrator)
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.
Independence will not be responsible for changes not processed due to
lack of proper notice. If you have any questions about updating your
provider information, please contact your Network Coordinator.
*To ensure appropriate setup in Independence systems, the
timelines outlined above also apply to behavioral health providers contracted
with Magellan Healthcare, Inc., an independent company, but they must submit
any changes to their practice information to Magellan via their online Provider Data
Change form by selecting the "Display/Edit Practice Info" link or 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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