Supporting Documentation Requirements for Practice-level Demographic Updates

Include supporting documentation:

• List of affiliated practitioner/NPIs that need to be linked or delinked to the practice location
• W-9 (for nonparticipating practices only)

Please clearly indicate if you are:

• Moving an existing practice location to a new address
• Closing an existing practice location office
• Adding an additional practice location

Include the information noted below to “link” practitioners to a specific practice location or to remove the affiliation of practitioners to a practice location.

Include supporting documentation:

• List of affiliated practitioners/NPIs that need to be linked to or removed from the practice location.

If the practitioner being removed is a Primary Care Practitioner (PCP) and has assigned panel members, please advise what should be done with these impacted panel members. Will the panel members:

• Move with the departing practitioner?
• Remain with the practice? Please indicate to which practitioner members may be transferred.

We will not consider requests to close PCP panels with fewer than 250 members. Specialists’ panels cannot close.

Include supporting documentation:

• W-9
• List of practice locations
• List of affiliated practitioners/NPIs per practice location

Send this request to the attention of your Network Specialist.

Note whether you are assuming liability of a prior TIN.

Include supporting documentation:

• W-9
• List of practice locations
• List of affiliated practitioners/NPIs per practice location

Send this request to the attention of your Network Specialist.

Include supporting documentation:

• W-9
• Billing phone number
• Billing fax number and/or email address