In accordance with your Provider Agreement (Agreement), the Provider Manual for Participating Professional Providers (Provider Manual), and/or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers (Hospital Manual), as applicable, you are required to notify Independence whenever key provider demographic information changes. Independence would like to remind you that 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 written notice to process most updates if the information submitted is accurate. For a complete outline of the advanced written notice time frames that Independence requires to process most updates, refer to the Administrative Procedures section of the Provider Manual.

Most changes to basic practice information can be quickly submitted using the Provider File Management transaction on the NaviNet^? web portal. Professional providers can submit updates to their Independence provider record, including:

• Add/Delete a participating practitioner to/from an existing practice
• Add/Delete an address (i.e., doing business as [DBA], check, mailing, main, or practice)
• Add/Delete contact name, title, or communication device type/number
• Add/Delete office hours
• Update ?Walk-in? acceptance status
• Update Patient and Appointment Options (i.e., accepting new patients)
• Update General Practice Availability (i.e., Urgent, Routine Visits, etc.)
• Update Member Access number (i.e., the telephone number that appears on the member's identification card ? which must be the location-specific telephone number for a patient to make an appointment)
• Update Electronic Medical Records (EMR) status
• Update the availability of other clinical staff (i.e., mid-wife, nurse practitioner, etc.)
• Update office accessibility and services (i.e., handicapped, parking, and communication and language services)

The Provider File Management transaction is not intended for use by facilities, skilled nursing facilities, ancillary providers, or providers contracted with Magellan Healthcare, Inc. (Magellan), an independent company.

If you are unable to process your request through the Provider File Management transaction, please submit a Provider Change Form. 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 215-238-2275. 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, Independence requires at least 30 days advanced written notice to process changes to your information as long as the information submitted is accurate.

Notice of all changes must be submitted in writing to our contracting and legal departments at the following addresses, or as provided in your Agreement:

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 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 Customer Service at 1-800-ASK-BLUE.

*To ensure appropriate setup in Independence systems, the same time frames also apply to behavioral health providers contracted with Magellan. Behavioral health providers 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.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most Independence members.