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.
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 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.
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:
- 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.