Provider Maintenance Form

Transcription

1 Provider Maintenance Form March 2018 A quick and easy new way for Anthem providers to submit demographic updates online

2 Submit demographic updates online The Provider Maintenance Form (PMF) is an online form used to request changes to existing practice profiles of Virginia physicians, practitioners, professionals and ancillary professional providers with Anthem Blue Cross and Blue Shield. We strive to keep accurate and regularly updated provider demographic information in the online provider directory. Keeping accurate health plan directories does require prompt notification from our contracted providers. One Provider Maintenance form submission can be utilized to ensure all lines of business are updated. 2 2

3 Need to add a provider? This maintenance form is not designed to add a provider, only to update existing records. Please use your Availity account to add a provider. From the Availity home page, be sure Virginia is your selected state, then go to Payer Spaces -> Anthem -> Provider Enrollment This is for both providers who are already credentialed with Anthem and those who are not. 3 3

4 The facts The change request should be submitted by the provider, practice manager or a designated person of authority. As a general rule, a minimum of 30 days advance notice of a provider demographic and/or practice change is required. Refer to the requirements in your Provider Agreement. Certain changes may be assigned a future effective date. Contractual guidelines may supersede the requested effective date of requests. An updated IRS W-9 form or other documentation that is required for certain changes should be attached to the online form prior to submission. 4 4

5 Where is the PMF located? Follow the below steps to access the PMF: Navigate to Select Find Resources for Your State in the Welcome, Providers! block Select Virginia Select drop-down menu Select Provider Forms Select Provider Maintenance Form 5 5

6 Where is the PMF located on Availity? Registered Availity users can navigate to (may not work on all browsers. Try Chrome or Mozilla) After logging in, select the state Virginia >Payer Spaces> Resources > Provider Maintenance Form. 6 6

7 Individual vs. Organization An individual is a unique health care provider who serves patients in one or many organizations. Use this to make a change for a person s record. An organization is a location, company or group of providers that deliver(s) health care through one or many providers. Use this to make a change for a location or a physician group. 7 7

8 Mailing/Remittance/Financial address changes Change to a remittance/billing address must be made by selecting the Organization tab. Correspondence affects bulletins, newsletters, and other notifications. 8 8

9 Changes for individual providers Personal profile updates for individuals: Accepting new patients* to open or close your panel. Address - add location add a new location to where the provider will see patients. Address - terminate to remove a location from which the provider no longer sees patients. address add a specific provider address to the directory. Handicapped accessibility update or add accessibility for a specific provider. Languages spoken add or delete languages spoken by a provider. NPI change a provider s individual National Provider Identifier (NPI). Network participation please contact your Network Manager. License number add additional license numbers to a provider profile. National Provider Identifier (NPI) replace an existing NPI with a new NPI. Office hours/days of operation update days and hours of operation for a single provider at a location. Patient age/gender preference update the age and gender preference for a specific provider. Phone/fax number add and/or delete a directory phone of fax number to display in the online directory. Network participation* request to remove or add a network to an individual provider agreement. Provider specialty* please contact your Network Manager. Tax Identification Number (TIN)* Change a provider specific individual tax ID number from one number to another(such as SS# to EIN). Do not use TIN Change to report practicing for a new TIN/Group. Termination of Provider Participation Agreement* Request for termination from participation. Provider name update- report a specific provider name change. 9 9

10 Changes for organizations Changes for an entire organization (group practice, location or company-level updates) Accepting new patients* to open or close your panel at the entire location. Address - add location add a new location affiliated to the entire Tax ID profile. Address - terminate to remove a location affiliation from the Tax ID profile. address add and/or delete the organization public provider directory address. Handicapped accessibility update or add accessibility for a location Languages spoken add or delete languages spoken by the staff at a location. NPI add an additional NPI or update/change existing Type 2 /billing NPI. Office hours/days of operation update the hours and days of operation at a location. Phone/fax number add and/or delete a directory phone or fax number for the location. Provider leaving group remove a provider from the affiliation of a Tax ID profile. Remove provider from location remove the provider record from a single location while maintaining affiliation with other locations for a Tax ID profile. Web address change the Web address that is presented in the online public provider directory. Network participation* please contact your Network Manager. Tax Identification Number (TIN)* only to be used to request to change from one number to another number under the same agreement. Termination of Provider Participation Agreement* request to terminate an agreement is a request for action and not a termination notice. Organization name update* change an organization name- (may require new contracting process) 1010

11 *Some changes are simply a request for action The Tax ID change, organization name change, closing panels, and termination of a participation agreement options are requests for action. These change requests are not considered a guarantee of participation or notice of termination. Each change request is subject to review and approval by a contract manager. Always refer to the change request or termination clause in your Provider Agreement for additional requirements. 111

12 What s next? Navigate to the General Information tab. This is the requested date the update will take effect. Providing advance notice of a change will help to ensure a timely update. Some changes cannot be made for retroactive dates and will be dated the same as the received date. All changes made on the form will apply to the person entered as the individual name or the location entered in the organization name. Important note: The data entered here should reflect the current information to which the change will be made. If the change has occurred in the past, enter that previous information here. 1212

13 What s next? (cont.) Next, navigate to the Select Updates tab. The flow chart at the top of the page displays the progress of the completed form. Select one or more updates. Only details that require an update are needed. 1313

14 What s next? (cont.) Navigate to the Specify Change Details tab. Enter your change details for the selected options. Instructions and tool tips are provided throughout the form for guidance. 1414

15 What s next? (cont.) When adding new detail, such as an , language spoken or hospital privileges, select the + to provide an additional entry field. Remember to provide updates when deleting the previous/old information from the record as applicable. 1515

16 Additional Form Functions Many selections offer a quick search function in the drop down choices. Start typing to narrow the search. Some fields will auto-populate with information to ensure accuracy. 1616

17 Attachments Attach any necessary documentation to support request (e.g., W-9 for TIN and name changes, copy of updated license for name changes, etc.) The attachment limit is 10MB. However, you can send a zipped file to decrease the size if necessary. 1717

18 Review for Submission After completing all necessary fields, review your submission page carefully to ensure accuracy. You may print this page by selecting the print icon at the top of the page. You may edit the submission details by selecting the pencil/edit icon. 1818

19 Review and Attest Attest to validate the entries are true and correct by checking the box and then selecting the Submit button. The submit button will not be functional until the Attest box is checked. 1919

20 Congratulations! You have completed the request form. You might be contacted by your Network Manager if any clarification is needed. Please be alert for any s and/or phone calls. s may come from your Network Manager directly or from ProviderDataMgmt. We suggest keeping a log to keep track of multiple requests so you know to which request the outreach is referring. Most changes require days to complete. Certain circumstances may take longer. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 2020