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 notice to process most updates, with the exceptions noted below:

• 30-day notice. Independence requires 30 days advanced 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.

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 policies and procedures for resigning or terminating from the network.

Facility and ancillary providers

Per your Agreement, all changes must be submitted in writing to our contracting and legal departments at the following addresses:

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 professional group provider 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 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.