Change of Status Form

ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER MAINTENANCE FORM

INSTRUCTIONSSubmit one form, with any necessary attachments, per tax identification number.

Section A, General Information:
· Complete required fields for tax identification number; practice name, and the Anthem id number.
· Specify solo or group practice. If group practice, indicate the number of physicians in the group.
· This form can be submitted electronically. Log into www.anthem.com, (1) choose Provider (2) choose State in drop down (3) click on Anthem & Answers, (4) click on Provider Maintenance Form
· If paper claim submission or Exempt from NPI fill out Legacy ID or Anthem PIN number
Section B, Reason for Submitting:
· Mark all applicable reasons for submitting this form.
· Specify the effective date of all changes
Comments:
Provide any additional comments, notes, or specific instructions.
Section C, Provider Information:
Most fields required.
· Include provider name, title, Social Security number, date of birth, gender, specialty, UPIN number, professional license number and CAQH id (specific to Credentialing). NPI Number.
· If updating multiple providers, complete their information on another sheet of paper or a copy of this form.
· Anthem E-business id.
· Note if provider should be suppressed from Anthem directory or Web pages.
Section D, Practice Address:
Required.
· Indicate your office location and your remit address (required).
or
· If changing address of practice, indicate old address.
· It is unacceptable to leave the remit address blank. Also it is unacceptable to put “same,” “same as practice address,” or “see above.” Any of these comments can cause a delay in processing.
· Include E-mail address only – no websites.
· Note if site should be suppressed from Anthem’s directory or Web pages.
Section E, Address Information Change:
Complete only if changing address.
· Indicate new (required) remit address.
· It is unacceptable to leave the remit address blank. Also it is unacceptable to put “same,” “same as practice address,” or “see above.” Any of these comments can cause a delay in processing.
· Include E-mail address only – no websites.
· Note if site should be suppressed from Anthem’s directory or Web pages.
Section F, Additional Office Locations:
· Include any additional office locations and all (required) billing addresses.
· Use a separate sheet of paper or a copy of this form to include additional addresses that do not fit in
this field.
· It is unacceptable to leave the remit address blank. Also it is unacceptable to put “same,” “same as practice address,” or “see above.” Any of these comments can cause a delay in processing.
· Include E-mail address only – no websites.
· Note if site should be suppressed from Anthem’s directory or Web pages.
Section G, Covering Physicians:

Applicable to PCPs and OB/GYNs in HMO networks

· List all group entities that cover for your practice.
· Include the effective dates of the covering arrangements.
Section H, Contact Signature:
· Sign and Date by Provider Office Contact.
· Your Anthem representative will sign during processing.

Section A. GENERAL INFORMATION

Practice Tax ID Number (EIN/SSN) / Group’s NPI
Group/Practice Name
If paper claim submission or Exempt from NPI fill out Legacy ID or Anthem PIN number
IN, KY and OH Provider Id Number/PIN:
If paper claim submission or Exempt from NPI fill out Legacy ID or Anthem PIN number
Missouri Provider ID Number:
If paper claim submission or Exempt from NPI fill out Legacy ID or Anthem PIN number
Wisconsin Provider ID Number:
Number of physicians this submission is pertaining to

Section B. REASON FOR SUBMITTING REQUIRED One Tax ID per PMF

* Date required* Effective Date of Add, Change or Delete: //

Adding Provider

/ /

Specialty Change

/ /

Practice Name Change

/ /

Remit Name Change

Deleting Provider (Supply reason below)

/ /

Provider Name Change

/ /

Practice Address Change

/ /

Remit Address Change

Adding Location

/ /

Deleting Location

/ /

Practice Phone # Change

/ /

Remit Phone # Change

Adding Provider To Location

/ /

Deleting Provider From Location

/ /

Practice Fax # change

/ /

Remit Fax # Change

Adding Web site

/ /

Changing Office Hours

/ /

Change email address

/ /

Add email address

Add Medicaid Number

/ /

Change NPI

/ /

Change Web site

/ /

Change Medicaid Number

Add NPI

/ /

Add Non Participating Provider

/ /

Adding Medicare Number

/ /

Change Medicare Number

Other. Briefly describe the reason for submitting this form:

Tax ID Change, Yes (Old Tax ID # is):

COMMENTS

Section C. PROVIDER INFORMATION Note:* indicates required fields for physician update.

*Provider First Name / *M I / *Last Name / *Title (MD/DO/etc.)
Please fill in only one of the following:: / *Primary Specialty Physician (i.e. FPR,INM)
/ *Specialty Care Physician (i.e. Cardiology, Gen.Surg)
/ *Other (i.e. PA, CRNA, CNM)
Is provider working in a Locum Tenum or Hospitalist capacity? Yes No
Is the provider working in a Primary Care or Specialists capacity
Taxonomy Code
Is the provider Board Certified for the specialty listed:
Yes No Not applicable to specialty / If No, when will you be sitting for the exam?
//
*Social Security Number
// / NPI
Numeric 10 in length / UPIN Number
/ *Professional License Number
CAQH ID Number: / Current Status of CAQH application: briefly explain:
*Date of Birth
// / *Gender:
M F
List in Anthem’s directory/web pages for members to make an appointment? Yes No / Accepting New Patients?
Yes No / Age limitations?
Minimum age Maximum age

Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In most of Missouri (excluding 30 counties in the Kansas City area) : RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc.RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross and Blue Shield of Wisconsin ("BCBSWi") underwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")underwritesor administers the HMO policies; andCompcareand BCBSWicollectively underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, IncThe Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association

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ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER MAINTENANCE FORM

Section D. PRACTICE ADDRESS. **REQUIRED ** Note: If changing address note PREVIOUS address here.COMPLETE REMIT ADDRESS IF DIFFERENT FROM PRACTICE ADDRESS

Practice Address / Remit Address (required)
City / State / Zip / City / State / Zip
County / County
Phone Number (patients can call)
() - / Fax Number
() - / Remit Phone Number
() - / Remit Fax Number
() -
Email Address / Group NPI
Medicare Group Number / Medicare Individual Number / Medicaid Group Number
/ Medicaid Individual Number
List site within Anthem’s directory/ web pages? / Yes / No / Access to Public Transportation? / Yes / No
Handicap Accessible? / Yes / No / Evening Hours? / Yes / No
Weekend Hours? / Yes / No / Days Office is Open: M T W T F

Section E. ADDRESS INFORMATION CHANGE Note: If changing address, place NEW address here.

Section F. ADDITIONAL OFFICE LOCATION (S) Use Separate Piece of Paper for Additional Practice Sites. COMPLETE REMIT ADDRESS (ES) IF DIFFERENT FROM PRACTICE ADDRESS (ES)

SECOND Practice Name:
Practice Address / Remit Address (required)
City / State / Zip / City / State / Zip
County / County
Phone Number (patients can call)
() - / Fax Number
() - / Remit Phone Number
() - / Remit Fax Number
() -
Email Address / Group NPI
Medicare Group Number / Medicare Individual Number / Medicaid Group Number
/ Medicaid Individual Number
List site within Anthem’s directory/ web pages? / Yes / No / Access to Public Transportation? / Yes / No
Handicap Accessible? / Yes / No / Evening Hours? / Yes / No
Weekend Hours? / Yes / No / Days Office is Open: M T W T F

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ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER MAINTENANCE FORM

THIRD Practice Name:
Practice Address / Remit Address (required)
City / State / Zip / City / State / Zip
County / County
Phone Number (patients can call)
() - / Fax Number
() - / Remit Phone Number
() - / Remit Fax Number
() -
Email Address / Group NPI
Medicare Group Number / Medicare Individual Number / Medicaid Group Number
/ Medicaid Individual Number
List site within Anthem’s directory/ web pages? / Yes / No / Access to Public Transportation? / Yes / No
Handicap Accessible? / Yes / No / Evening Hours? / Yes / No
Weekend Hours? / Yes / No / Days Office is Open: M T W T F
FOURTH Practice Name:
Practice Address / Remit Address (required)
City / State / Zip / City / State / Zip
County / County
Phone Number (patients can call)
() - / Fax Number
() - / Remit Phone Number
() - / Remit Fax Number
() -
Email Address / Group NPI
Medicare Group Number / Medicare Individual Number / Medicaid Group Number
/ Medicaid Individual Number
List site within Anthem’s directory/ web pages? / Yes / No / Access to Public Transportation? / Yes / No
Handicap Accessible? / Yes / No / Evening Hours? / Yes / No
Weekend Hours? / Yes / No / Days Office is Open: M T W T F
FIFTH Practice Name:
Practice Address / Remit Address (required)
City / State / Zip / City / State / Zip
County / County
Phone Number (patients can call)
() - / Fax Number
() - / Remit Phone Number
() - / Remit Fax Number
() -
Email Address / Group NPI
Medicare Group Number / Medicare Individual Number / Medicaid Group Number
/ Medicaid Individual Number
List site within Anthem’s directory/ web pages? / Yes / No / Access to Public Transportation? / Yes / No
Handicap Accessible? / Yes / No / Evening Hours? / Yes / No
Weekend Hours? / Yes / No / Days Office is Open: M T W T F

Section G. COVERING PHYSICIANS Note: For PCPs and OB/GYNs in HMO Networks only

Group Entity Name: / Specialty: / Nine (9) Digit Tax ID: / Effective Date:
Group Entity Name: / Specialty: / Nine (9) Digit Tax ID: / Effective Date:

Section H. CONTACT SIGNATURE

Provider Office Contact / Phone Number
() -
. / Date
Anthem Consultant / Phone Number
() -
. / Date
I hereby verify that the information that is provided on this form is accurate as presented. Please note: To help avoid processing delays, review this form before submitting. Incomplete forms may be returned for additional information.

5/2008 Page 6 of 6

ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER MAINTENANCE FORM

Change of Status Form

INSTRUCTIONSSubmit one form, with any necessary attachments, per tax identification number.

Applicable to PCPs and OB/GYNs in HMO networks

Section A. GENERAL INFORMATION

Section B. REASON FOR SUBMITTING **REQUIRED** One Tax ID per PMF

* Date required* Effective Date of Add, Change or Delete: //

Adding Provider

Specialty Change

Practice Name Change

Remit Name Change

Deleting Provider (Supply reason below)

Provider Name Change

Practice Address Change

Section B. REASON FOR SUBMITTING REQUIRED One Tax ID per PMF