Provider demographic changes

When adding or terminating a provider from your practice, or making an address or phone number change, you may use our Provider Demographic Change Notification form. You’ll find this in the Forms section of our online provider manual. Include all pertinent information in any other document you choose to send.

Some changes require waiting periods as noted on this form, so please allow plenty of time for the change to occur in our system. NCQA requirements are to give our members 30 day notice for primary care provider terminations. We need and appreciate your help in meeting this requirement by providing us notice 90 days in advance.

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