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A10ITHElD'I Bi,UE CROSS AND BLUE SHIELD JPROVIDER MAINTENA1eTCE FORM Anthema '=•o W. LNSTauCTIONS Subnniit one foru3, dvith aBy necessary attasinmenis, per tas identificaTion nurnber. , Section A, General infarmation: 0 Complete required fields for tax identification number; practice name, and the Anthem id number. • Specify solo or group practice. If group pracrice, indicate the number ofphysicians 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 II3 or Anthem PIN number Section B, Reasan for Submitting: • Mark all applicable reasons for submitring this form. • Specify the effective date of all changes Comments: Provide any additional comments, notes, or specific instructions. Section C, Provia3er Informarion: Most fields reqzcired. • Include provider name, ride, 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. a Indicate your office locarion and your remit address (required). OY • If changing address of practice, indicate old address. • I# is unacceptable to leave the remit adciress blank. Aiso 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 pracrice 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, Additiona3 Offce Locations: ? Include any additional office locations and all (required) billina 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 uaacceptable 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 Phys'scians: Applicable to PCPs and OB/GYivs in M, 10 networks • List all group entities that cover for your practice. m Include the effecrive dates of the covering arrangements. Section H, Contact Signature: a Sign and Date by Provider Office Contact. * Your Anthem representative will sign during processing. arM e Kansas Ci(y area) 1 ten by HMO f.Aissoun, J? ) undernrftes or )S marks of Ne Blue