Supporting Documentation Requirements for Practice-level Demographic Updates
Please include the information/documentation noted along with your request for us to make the following types of changes/updates to your demographic information.
Changes in Practice Location (e.g., adding, closing or moving practice locations)
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
Affiliated Practitioner Changes
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.
Closing/Opening a PCP Panel
We will not consider requests to close PCP panels with fewer than 250 members. Specialists’ panels cannot close.
Practice TIN Change
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.
Purchase of Another Practice/Entity
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.
Billing Address/Billing Company Changes
Include supporting documentation:
- W-9
- Billing phone number
- Billing fax number and/or email address