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Demographic Maintenance Guide
AmeriHealth HMO, Inc. | AmeriHealth Insurance Company of New Jersey
Demographic Maintenance Guide
October 2019
Demographic Maintenance Guide
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Introduction AmeriHealth HMO, Inc. and AmeriHealth New Jersey (collectively, AmeriHealth New Jersey) are excited to offer you a one-stop reference tool that provides the designated methods for the submission of demographic changes. It is critical that you regularly review your demographic information in our online Find a Doctor tool to ensure that all of your information is accurate. Our members, your patients, rely on provider directories to make informed choices about care. This guide is specific to AmeriHealth providers located in New Jersey. If you are located in Pennsylvania, please use the guide located here.
Required lead time when updating your provider information If changes to your demographic information are not submitted timely and accurately, it may impact accurate claim payment. Therefore, we encourage you to adhere to the following lead-time requirements when updating your provider information:
• 30-day notice. AmeriHealth New Jersey requires 30 days advance written notice for the following changes/updates to your practice information: – updates to address, office hours, total hours, phone number, or fax number; – changes in selection of capitated providers (HMO primary care physicians [PCP] only); – addition of new providers to your group (either newly credentialed or participating); – changes to hospital affiliation; – changes that affect availability to patients (e.g., opening your panel to new patients).
• 60-day notice. AmeriHealth New Jersey requires 60 days advance written notice for addition or closure of a PCP practice or it’s panel to additional patients. For PCP-specific changes, 60 days advance written notice is required due to the impact on member movement and incentive programs.
• 90-day notice. AmeriHealth New Jersey requires 90 days advance written notice for resignation and/or termination from our network.
AmeriHealth New Jersey will not be responsible for changes not processed due to lack of proper notice from the Provider. Refer to the Administrative Procedures section of the Provider Manual for Participating Professional Providers and/or Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers for additional information.
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Special instructions Before proceeding with the review of this guide, there are special instructions for submission of demographic changes applicable to the following provider types:
• Magellan provider. Behavioral health providers contracted with Magellan Healthcare, Inc. (Magellan) are required to notify Magellan and/or confirm any changes in administrative practice information using their online Provider Data Change Form (PDCF). By using the PDCF, providers can update information online in real time. Some changes to provider information may require notification to your Magellan contact, the PDCF application will direct you when these notifications need to occur. Magellan providers can follow-up on their requests by contacting the Magellan Provider Services Line at 1-800-788-4005.
• Facilities, skilled nursing facilities, and ancillary providers (organizational providers). Notice of all changes must be submitted in writing to our contracting and legal departments at the following addresses, or as provided in your Agreement: Contracting: Legal: AmeriHealth New Jersey AmeriHealth Attn: Senior Vice President, Provider Attn: Deputy General Counsel, Managed Care Network Operations 1901 Market Street, 43rd Floor 259 Prospect Plains Road, Building M Philadelphia, PA 19103 Cranbury, NJ 08512 Please allow 30 business days after submission of request for completion. We encourage providers to review our online Find a Doctor tool, after the allotted time to confirm completion of your change request. For follow-up on your open request, you can contact your Provider Partnership Associate. You can find your Provider Partnership Associate through the online search tool.
• Non-participating professional provider. If you are a non-participating professional provider that requires demographic changes, you must submit a Provider Change Form. Instructions on how to complete and submit the form are located on page 6.
Submitting changes to your provider information There are currently three methods for participating professional providers to submit demographic changes. If you are not able to use the primary submission method due to system limitations, we ask that you move to the secondary or tertiary method as applicable.
• Primary: Provider File Management transaction on the NaviNet® web portal (NaviNet Open)
• Secondary: Provider Change Form
• Tertiary: Provider Partnership Associate
Submitting multiple provider demographic changes If you have multiple changes that will crossover more than one submission method, proceed to using the Tertiary method on page 6 for submission.
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Primary: Provider File Management Your primary method of completing a demographic change request should be via the Provider File Management transaction on NaviNet Open, which allows professional providers to view and submit specific real-time updates to their AmeriHealth New Jersey provider record. Provider File Management exclusions Provider File Management is not intended for use by:
• Magellan providers
• Facilities, skilled nursing facilities, ancillary providers, or dental (e.g., oral surgeon) providers Note: These provider types have alternative methods for demographic updates.
• If you are part of an Integrated Delivery System (IDS), you should follow the demographic submission process as outlined by your Provider Partnership Associate.
Accessing the Provider File Management transaction on NaviNet Open Providers can access the Provider File Management transaction through NaviNet Open by selecting Provider File Management from the AmeriHealth New Jersey Workflows menu. For complete details on how to make updates to your provider record via Provider File Management and any additional information relative to this functionality, please refer to the Provider File Management Guide, which can be found under User guides and webinars in the NaviNet Open section of the AmeriHealth Provider News Center. This guide also includes contact information for training and education on the use of the Provider File Management transaction. The next page lists demographic changes that can be updated via the Provider File Management transaction, which are separated by practice level and practitioner level.
Important information on updating your provider record Providers are strongly encouraged to use the Provider File Management transaction to update provider records. If AmeriHealth New Jersey receives provider record updates that can be submitted using the Provider File Management transaction, a member of our Provider eBusiness team may contact that provider to assist them in using the transaction to make the necessary updates. This will allow our team to receive user feedback on the transaction and help improve the overall user experience for our network.
Time frame to process through Provider File Management Provider File Management requests are completed in real time, except for pended requests (i.e., removal of a practitioner from his only vendor record, update to practitioner education). These requests are updated within 30 business days of submission. Refer to the Provider File Management Guide for details on how to view pended requests. We encourage providers to review our online Find a Doctor tool, after the allotted time to confirm completion of your change request (see page 8). If you need assistance with submitting a demographic change via Provider File Management, please use our online Provider eBusiness Inquiry form. For follow-up on a submission that has been pended for more than 30 days, you can contact your Provider Partnership Associate.
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Practice-level Provider File Management edits You may perform the following functions as they relate to your practice:
Add/Delete Update
• A participating practitioner to/from an existing practice
• An address* (i.e., doing business as [DBA], check, mailing, main, or practice) ‒ All practice addresses must be within
the same state. • Contact name, title, or communication
device type/number • Office hours
• “Walk-in” acceptance status • Patient and Appointment Options* (i.e.,
accepting new patients) • General Practice Availability (i.e., Urgent,
Routine Visits, etc.) • Member Access number (i.e., the
telephone number that appears on the member’s identification card – which must be the location-specific telephone number for a patient to make an appointment)
• Electronic Medical Records (EMR) status • The availability of other clinical staff (i.e.,
midwife, nurse practitioner, etc.) • Office accessibility and services (i.e.,
handicapped, parking, and communication and language services)
*This function is not available to PCP practices due to possible impacts on capitation and/or incentive programs.
Individual practitioner-level Provider File Management edits You may perform the following functions as they relate to individual practitioner profiles, providing they hold a primary affiliation with your practice:
Add Add/Delete Update
• Additional educational background
• Hospital affiliations
• The address (i.e., main, practice, or check) to which a practitioner is affiliated
• Gender, race, or ethnicity • Practitioner languages • Photos – upload/remove • Patient and Appointment
Options (i.e., accepting new patients)
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Secondary: Provider Change Form If you do not meet one of the provider type exclusions noted on page 4, and the Provider File Management transaction is not an available submission method, please utilize our Provider Change Form. The Provider Change Form, is available in the Tools and Resources section of our website. Please Refer to Appendix A for detailed information on completing the Provider Change Form.
Tertiary: Provider Partnership Associate If the primary or secondary methods of submission do not meet your needs, contact your Provider Partnership Associate. You can find your Provider Partnership Associate through the online search tool. Please refer to Appendix B for detailed information on what must be included in your email request. These alternate submission methods are in place to accommodate supplemental documentation that is required to complete the request.
Time frame to process updates through the Provider Change Form Please allow 30 business days after submission of request for completion. For follow-up on your open request, you can contact your Provider Partnership Associate.
Time frame to process updates through Provider Partnership Associate You will receive acknowledgment of your request from your Provider Partnership Associate. Please allow 30 business days after submission of your request for completion. We encourage providers to review the online Find a Doctor tool after the allotted time to confirm completion of your change request. For follow-up on your open request, you can contact your Provider Partnership Associate.
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Using the appropriate submission method The chart below indicates the type of demographic changes that should be submitted through the Provider Change Form or email/fax as applicable:
Provider and update type Reason you cannot complete via Provider File Management Submission method
PCPs
Change in practice name W-9 required Provider Change Form
Change in tax identification number
W-9 required and additional administrative impacts
Provider Partnership Associate
Add/Delete a practice address Impacts to member movement
Change in capitation site Impacts to member movement
Member movement requests Additional administrative information required
Panel status (accepting new patients, open to existing, closed to all patients)
Impacts to incentive programs
Adding affiliation to a practice located in a different state Cross-credentialing required
Add/Change provider specialty W-9 required and additional administrative impacts
Acquiring a practice W-9 required and additional administrative and contractual impacts
Termination of a practice from the network
Possible impacts on capitation and/or incentive programs
Specialists
Change in practice name W-9 required Provider Change Form
Change in tax identification number
W-9 required and additional administrative impacts
Provider Partnership Associate
Adding affiliation to a practice located in a different state Cross-credentialing required
Change practitioner specialty Claim impacts
Acquiring a practice W-9 required and additional administrative and contractual impacts
Termination of a practice from the network Possible impacts to member access
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Display in our online Find a Doctor tool Our online Find a Doctor tool is updated weekly with new updates pulled from our corporate provider repository (CPR) on Saturdays. Therefore, new or updated information is typically displayed by the following Tuesday, pending any uncontrollable systemic delays. Examples:
Change method used Day of submission/receipt
Day of completion in
CPR
Weekly Find a Doctor
tool update
Find a Doctor tool
display
Provider File Management Monday, July 1 Monday, July 1 (real time)
Saturday, July 6
Tuesday, July 9
Provider Change Form Monday, July 1
Friday, August 9
(30 business days)
Saturday, August 10
Tuesday, August 6
Provider Partnership Associate Tuesday, July 9 Tuesday,
August 20 Saturday, August 24
Tuesday, August 27
Questions If you are not able to locate the necessary information to perform your specific demographic change or you would like to offer any comments or suggestions, please email us at [email protected] so we can continually improve this guide. Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most AmeriHealth New Jersey members.
NaviNet® is a registered trademark of NantHealth.
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Appendices
Appendix A Provider Change Form
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Provider Change Form continued
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Provider Change Form definitions Field
number/title Subfields Field definition/notes Data type (Required/Optional)
1. Current practice information
Group practice name
This subfield is the billing provider name on your W-9.
Required
Group practice NPI number
This subfield is the billing provider NPI that is registered for doing business with AmeriHealth New Jersey.
Address This subfield is the address associated with your practice.
Fax This subfield is the fax number associated with your practice.
Contact person and Phone #
This subfield is the person’s name and telephone number to contact if there are questions regarding the change request.
Authorizing signature and Phone #
This subfield is the person’s name and telephone number who takes responsibility for the change request.
Effective date of change
These subfields are the date that the changes should go into effect and the date the form was submitted. Today’s date
2. Provider change information
Type of change
Select the applicable types of changes that you are trying to make. • Update current office information
(Field 3) – Practice name – Address – Phone number – Fax number
• Add/Delete an office location (Field 4)
• Add/Delete a physician to/from an existing office location (Field 5)
• New mailing address (Field 6) • New payment information
(Field 7)
Required
3. Update current office information
Group practice name These fields allow you to keep, delete,
or update your current practice information. If updating, fill out the relevant information.
Required Address
Telephone
Fax
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4. Office locations
Group practice name
These fields allow you to add or delete office locations associated with your practice. If you have to add more than one office location, use page 2, Field 9 of the form.
Optional
Group practice NPI
Address
Telephone
Fax
Effective date
5. Physicians
Name These fields allow you to add or delete physicians associated with your practice. If you have to add more than one physician, use page 2, Field 10 of the form.
Optional Specialty
Individual provider NPI
Effective date
6. New mailing address
Address These fields allow you to update your mailing address if different from your current practice information address in Field 1.
Optional Telephone
Fax
Federal tax ID number
7. New payment information
Address These fields allow you to update your payment address if different from your current practice information address in Field 1.
Optional Telephone
Fax
Federal tax ID number
8. Current practice information
Group practice name
These fields are required if adding/deleting offices and/or physicians from page 1. Same as Field 1 on page 1.
Required Group practice NPI number
9. Additional office locations
n/a This field allows you to add or delete locations in addition to the one already listed in Field 4.
Optional
10. Additional physicians n/a
This field allows you to add or delete physicians in addition to those listed in Field 5.
Optional
Miscellaneous
The complete Provider Change Form should be faxed or mailed to:
Fax: (preferred method) Mail: 215-238-2275 AmeriHealth New Jersey
Attn: Network Administration P.O. Box 41431 Philadelphia, PA 19101-1431
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Appendix B Required information for email/fax submissions Any demographic change request submitted by contacting your Provider Partnership Associate should include the following details:
• nature of the change
• contact name and telephone number
• group practice name
• group practice NPI number
• impacted individual practitioner name
• impacted individual practitioner NPI number
• impacted group practice location(s)
• effective date of change request
Provider type and change request Additional information required Comments
PCPs
Add/delete a practice address
• Add/delete new address, identify whether members should be moved to another practice address
• Provide the From and To NPI numbers
If another practice address is not provided for member movement, members will be moved to an unassigned status and be advised to request a new PCP.
Change practitioner specialty
• Justification for change in specialty type
• Copy of Curriculum Vitae (CV) • W-9
The provider must contact the credentialing area at [email protected] for approval. They will provide instructions on any additional information needed.
Change in capitation site
• Name, NPI number, and specialty type of the new capitation site n/a
Member movement request
• Name and ID number of the member • A copy of the termination letter that
was sent to the member • Long Term Care change form, as
applicable
The practice must also continue treating the member for current medical conditions for 30 days after ending the physician-patient relationship to allow time for the member to select a different treating physician.
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Provider type and change request Additional information required Comments
PCPs (continued)
Change in panel status (accepting new patients, open to existing, closed to all patients)
• Indicate which status is applicable to your practice: ‒ Accepting new patients (default) ‒ Open to existing patients only, not
accepting new patients ‒ Closed to all patients
If you select a change in your panel status that will not allow new patients, this change will impact your incentive program status If you select Open to existing, this is applicable regardless of your current patient’s coverage. Therefore, if one of your current PPO patient’s changes their coverage to an HMO plan, they maintain their “existing patient” status and are added to your HMO capitation panel.
Adding affiliation to a practice located in a different state
• Malpractice face sheet • License for alternate state • DEA/CDS for alternate state • Agreements for alternate state
Prior to a practitioner being affiliated with a practice that is in a different state than what was contained on their original credentialing request, they must be cross-credentialed in the other state.
Establishing a new practice OR Acquiring a practice
• W-9 • Malpractice face sheet • Office hours • Names of the practitioners and their
NPI numbers that are to be affiliated with new practice
• If members are moving from a previous practice, provide the From and To NPI numbers.
• Mailing address for correspondence • Mailing address for payments • Age range of patients to be seen • Telephone number • Fax number • Applicable capitation sites
Please review your provider participation agreement for additional requirements that may apply. If additional information is needed, you will be contacted in accordance with your agreement.
Termination of a practice from the network
• If members are moving from a previous practice, provide the From and To NPI numbers.
• Must submit a letter indicating that the practice is closing and the effective date
• Brief explanation as to why the practice is closing
If another practice NPI is not provided for member movement, members will be moved to an unassigned status and be advised to request a new PCP.
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Provider type and change request Additional information required Comments
Specialists
Change in tax identification number • W-9 n/a
Adding affiliation to a practice located in a different state
• Malpractice face sheet • License for alternate state • DEA/CDS for alternate state • Agreements for alternate state
This information requires approval from our credentialing area before any changes can be implemented.
Change practitioner specialty
• Justification for change in specialty type
• Copy of Curriculum Vitae (CV) • Copy of Board Certification (only for
PCP [e.g., if a specialist is requesting to change to a PCP])
• W-9
The provider must contact the credentialing area at [email protected] for approval. They will provide instructions on any additional information needed.
Establishing a new practice OR Acquiring a practice
• W-9 • Malpractice face sheet • Office hours • Names of the practitioners and their
NPI numbers that are to be affiliated with new practice
• Mailing address for correspondence • Mailing address for payments • Age range of patients to be seen • Telephone number • Fax number
Please review your provider participation agreement for additional requirements that may apply. If additional information is needed, you will be contacted in accordance with your agreement.
