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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: 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.
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