Provider Maintenance Form instructions
When making a change to a group name or tax ID for M.D., D.O. or DPM physicians, or physician groups who have signed a
Prudent Buyer PPO Physician Agreement
, complete the Prudent Buyer Physicians and Physicians Group Amendment and attach it to your request along with a completed IRS form W-9 .
- Complete the General Information section to identify the practitioner or organization for which the change needs to be made.
- Select option tiles to identify the change you wish to make. Select only the change option tile(s) that require a change. You can remove selections by navigating back and clicking the tile selection again.
- If your office is moving, enter the old address in the General Information section. Select the tile for Address - Terminate to set an end date for that address and select Address - Add Location to enter the new location.
- Attach any necessary documentation to the Provider Maintenance Form prior to submission. Necessary documentation may include, but is not limited to: Tax IRS form W-9 (necessary to change a payment remittance address or tax identification number), copy of the provider’s state license (necessary for a name change) or other documentation that may help explain the submission.
- When making an Organization change, all providers at the location will be affected by the change. If the requested changes do not apply to all providers, please include an explanation as an attachment—along with the providers’ names and NPI—to ensure the update is accurate. If there are multiple individual variances for a single organization location, please submit separate forms using the Individual option.
- Carefully evaluate the information on the Review for Submission page. Once the form is submitted, you cannot recall or correct it.
- Ensure the data entered is accurate.
- Check the box to agree to the Attestation Statement
- Select the Submit button at the bottom of the form to finalize the submission.
- Look for an email confirmation containing the submission reference number. This confirmation will be sent to the email address entered in the Contact Information section of the General Information page. Another email will be sent when the submission has been processed by Anthem. Make note of this reference number. You will need to reference this number if you need to follow up on this submission.
Submission of this form is a request for action not a guarantee of participation or notice of termination. All change requests are subject to review and approval by a contract manager. Please refer to your Provider Agreement for additional requirements.
Note: We require 30 days advance notice of a provider demographic and/or practice change and 90 days advance notice for terminations to allow us time to transition members to a participating provider. Please refer to the termination clause in your Provider Agreement for additional requirements.