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Information for Connecticut

Provider Maintenance Form

Beginning June 1, 2023, providers contracted with Anthem Blue Cross and Blue Shield (Anthem) should utilize Availity’s Provider Demographic Management (PDM) application hosted on to request changes to existing practice information.

Roster Automation is a new system upgrade that will read a standardized form, identify necessary changes, and update the demographic system.

Roster Automation Rules of Engagement

Roster Automation Standard Template

If your organization is not currently registered with Availity, the person(s) designated as your administrator(s) should go to and select register in the upper right-hand corner of the webpage in order to obtain an Availity account. You may also navigate directly to Availity’s registration website by clicking here: Availity registration. Provider Maintenance Form will be available until September 30, 2023.

Provider Maintenance Form

If you are an existing contracted group and wish to add a provider, or if you are a non-contracted provider and would like to join Anthem’s network:

Begin Application

Tips for Individuals and Organizations

Select 'Individual' if you wish to make a change for a single practitioner. Examples of changes include, but are not limited to:
  • specialty,
  • areas of expertise,
  • specific days or hours of operation at a location,
  • languages spoken by the practitioner,
  • federal tax identifier,
  • address (add or terminate an address location where the practitioner can see Anthem members), etc.

Select 'Organization' if you wish to make a change for an entire location. Examples of changes include, but are not limited to:

  • remittance/payment address for a group,
  • new address location for all providers in a group,
  • remove a provider from a group or single location,
  • days and hours of operation for a location, etc.
Note: Change options vary by state. Remittance Address changes must be made in the 'Organization' tab.

Provider Maintenance Form Instructions

  • 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 120 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.