User Guidelines

This Non-Participating Provider Change form should be used only by non-participating providers (no signed agreement with this Health Plan). This form is to request a demographic data change if the non-participating provider has previously filed a claim and has demographic information already loaded to the claim processing systems.

Steps to complete the Non-Participating Provider Change Form

  1. Download and save the form to your personal computer.Do not complete this form on the website.
  2. All fields are mandatory. Incomplete responses will delay your request for change.
  3. Carefully review drop down lists. Drop down options will be apparent after clicking into the answer box.
  4. Attach W-9; Signature Page; and/or copy of License or Certification as required.
  5. Upon completion of all fields, click on the “submit” button to finalize the change request. After receipt of the change request, it will be reviewed and processed within 10 business days.

For greater detail, see the following pages.

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Procedure to complete the form

All fields on this form are required. Incomplete responses will delay your submission.

Select an appropriate option (Yes/No) from the drop down list for question Do you currently have a signed contract agreement with Health Plan?

If user has a signed contract, attach the signed copy by clicking on “Click to upload” button located at the bottom of the form.

If user selects “No” to answer “Has this provider submitted any claims?” from the provided dropdown list, the below error message will be displayed. This form is only used to requesta change on an existing record. If there is no existing record, it is not necessary to continue completing the form.

Fill the Provider Name, Provider Contact Name in respective boxes and additionally CurrentRole/Title in organization needs to be included (i.e. Dr., MBBS, and Physician)

Phone, Email and Fax are 3 options listed for “Preferred mode of communication” field. User needs to select their appropriate mode of communication from the drop down list.

Once an option is selected in the preferred method of communication field, user will be asked to re-enter the information for cross-verification purposes. The information needs to be keyed in twice for validation purposes. If the re-entered information does not match, an error message will be prompted after submission. Fields that requires corrections will be highlighted in red.

Select an option from the below questions.

Three options are listed for the Provider File Identifier field: Tax ID, NPI and License #. The length of Tax ID must be of 9 digits and should be numeric (1, 2, 3...)

Once USER selects “Tax Id” in Provider File Identifier field, then after clicking on “Submit” button, the below message box would appear. This would confirm whether the Tax Id entered aligns with the Organization/Provider or not.

In case of NPI, it should be 10 numeric characters (e.g. 1234567890)

Select state from drop down

Enter the provider primary and secondaryspecialty in respective columns. If there is no secondary specialty, please enter “not applicable or N/A”

Enter the Practice and Billing Address in the below fields. The information needs to be keyed in twice for validation purposes. If the re-entered information does not match, an error message will be prompted after submission. Fields that requires corrections will be highlighted in red.** In order to add content in second line, press “Alt+Enter” keys to continue.

  • Enter Practitioner medical title, Med ID and Facility Type in respective fields.

In the Change Option Request field, below options are available in the drop down

  • Name
  • Practice Address
  • Billing Address
  • Correspondence Address
  • Phone Number
  • Tax ID
  • Specialty

In case the user wants to update the Name, then while selecting “Name” from drop down list, a dependent box/field will be displayed with the appropriate attributes in the grid (far left column) as First/Middle/Last name to facilitate users to change/update the specific fields.

Put the “old” information in Former/Old info field. New information will have to be entered and re-entered for validation. See example:

If user needs to attach copy of W-9, Signature Page, License or Certification etc. Or any relevant document, he/she can attach one or multiple documents irrespective of file types (xls, doc, pdf, etc.) by clicking on “Click to upload” button.

  • Name (W-9, copy of license or certification)
  • Practice Address (W-9)
  • Billing Address (W-9)
  • Correspondence Address (W-9)
  • Phone Number (nothing needed to change phone number)
  • Tax ID (W-9, copy of license or certification)
  • Specialty (W-9, copy of license or certification)

Final Submission

Once all fields are entered, click on “Submit” button for further processing.

Additional Information: below are the auto validations which will be triggered once the submit button is clicked:

  • Blank fields will be checked, error message would be prompted in case of missing information.
  • Validate re-entered information for Phone, Fax, Email, Practice Address, Billing Address and all change type fields.
  • Check the Tax ID criteria (Limit of 9 numeric characters.
  • Check the NPI criteria (Limit of 10 numeric characters).

After successful authentication, the form and attachments will automatically route by Email to the respective Health Plan

After clicking the “Submit” button, a confirmation message will be displayed.

Reset Procedure

To reset or clear all fields populated with information on the form, click on the Reset button.

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