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
provider demographic 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.
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
written notice to process updates to
address, phone number, or fax number, as well as change in ownership.
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: Vice President, Contracting and Reimbursement
- 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:
- – Group practices: A signature from a legally authorized
representative (e.g., physician or other person who
signed the professional group provider agreement or one who is legally
authorized to bind the group practice) of
the practice is required.
- – Solo practitioners: A signature from the individual practitioner 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. Failure to
provide proper advanced written notice to Independence may delay or otherwise
affect provider payment. 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.