AmeriHealth would like to remind you about the importance of submitting changes to your provider information in atimely 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. Peryour AmeriHealth Professional Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider Agreement(Agreement), you are required to notify AmeriHealth whenever key provider demographic information changes.

Professional providers

As outlined in the Administrative Procedures section of the appropriate Provider Manual for Participating Professional Providers (Provider Manual), AmeriHealth requires 30 days advanced notice to process most updates, with the exceptions noted below:

• 30-day notice. AmeriHealth requires 30 days advanced notice for the following changes/updates to your practiceinformation:
• – 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. AmeriHealth requires 60 days advanced written notice for closure of a PCP practice or panel toadditional patients.
• 90-day notice. AmeriHealth requires 90 days advanced written notice for resignation and/or termination from ournetwork.

Note: AmeriHealth will not be responsible for changes not processed due to lack of proper notice.

Professional providers can use the Provider Change Form to quickly and easily submit most of the changes totheir basic practice information. Please be sure to print clearly, provide complete information, and attach additionaldocumentation as necessary. The forms can be found and submitted as follows:

• AmeriHealth New Jersey. The Provider Change Form is available here. Completed forms can be faxed to Network Administration at 215-988-6080 or mailed to:
• AmeriHealth New Jersey
• Attn: Network Administration
• P.O. Box 41431
• Philadelphia, PA 19101-1431
• AmeriHealth Pennsylvania. The Provider Change Form is available here.Completed forms can be faxed to Network Administration at 215-988-6080 or mailed to:
• AmeriHealth
• Attn: Network Administration
• P.O. Box 41431
• Philadelphia, PA 19101-1431

If faxing, 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 AmeriHealth network? in the Administrative Procedures section of theProvider 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 30 days advanced written notice to process updates to address, phone number, or fax number, as well as change in ownership.

Note: AmeriHealth will not be responsible for changes not processed due to lack of proper notice.

Per your Agreement, all changes must be submitted in writing to our contracting and legal departments as follows:

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 whosigned the professional group provider agreement or who is legally authorized to bind the group practice) of thepractice 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 ofyour W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed.

If you have any questions about updating your provider information, please contact your Provider PartnershipAssociate or Network Coordinator.

* To ensure appropriate setup in AmeriHealth systems, the timelines outlined above also apply to behavioral health providers contracted withMagellan Healthcare, Inc., but they must submit any changes to their practice information to Magellan via their online Provider Data Change format www.MagellanHealth.com/provider by selecting the ?Display/Edit Practice Info? link or by contacting their Network Management Specialist at
1-800-435-7670, extension 53869, for assistance.