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 written notice to process most updates, with the exceptions noted below:

• 30-day notice. Independence requires 30 days advanced written 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.

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 these policies and procedures.

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.

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 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 Customer Service at 1-800-ASK-BLUE.

*To ensure appropriate setup in Independence systems, the same time frames also apply to behavioral health providers contracted with Magellan Healthcare, Inc., an independent company. Behavioral health providers 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.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.