AmeriHealth would like to remind you that, per your AmeriHealth Professional Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider Agreement (Agreement), you are required to notify AmeriHealth 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*

AmeriHealth 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 AmeriHealth 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, available at AmeriHealth New Jersey website and at AmeriHealth Pennsylvania website.

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 AmeriHealth 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, AmeriHealth 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 as follows:

• AmeriHealth New Jersey:
• AmeriHealth New Jersey
• Attn: Vice President, Provider Network Operations
• 259 Prospect Plains Road, Building M
• Cranbury, NJ 08512

• AmeriHealth
• Attn: Deputy General Counsel, Managed Care
• 1901 Market Street, 43rd Floor
• Philadelphia, PA 19103

• AmeriHealth Pennsylvania:
• AmeriHealth Attn: Senior Vice President, Provider Networks and Value-Based Solutions
• 1901 Market Street, 27th Floor Philadelphia, PA 19103
• AmeriHealth 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.

AmeriHealth 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 Provider Partnership Associate or Network Coordinator.

* Behavioral health providers contracted with Magellan Healthcare, Inc. 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 1-800-435-7670, extension 53869, for assistance.