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 practice 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 that result 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.
* 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 by selecting the ?Display/Edit Practice Info? link or by contacting
their Network Management Specialist at 1-800-866-4108 for
assistance.