Care Provider Demographic Information Update Please use this form for a single care provider practitioner update. Incomplete forms will not be processed. Fields with an asterisk (*) are required for practitioners providing care under all UnitedHealthcare plans, including UnitedHealthcare Military & Veterans. If additional space is required, please include a separate roster with this form. A W-9 form is required when adding new tax IDs and making name changes. You confirm that any information not updated on this form or roster is current. UnitedHealthcare will use current data and the updates you provide to publish accurate care provider directories. Index: Section I Care Provider Information - Required Section II Updates: Taxpayer Identification Number, Addresses, Contact Information Section III Definitions and National Provider Identifier (NPI) requirements Section IV Sign and Submit Section I Care Provider Information *Care Provider Name: This is a name change. Attach a copy of the W-9 form for name changes. Previous Care Provider Name: Effective Change Date (MM/DD/YYYY): *Taxpayer Identification Number (TIN): Name of group or organization associated with this care provider/tin *Care Provider Information When adding a new care provider, all questions are required. When updating a care provider s information, fill out the applicable fields. 1. Date of birth (MM/DD/YYYY): 2. Gender: Male Female 3. Does the care provider have a Medicare identification number? Yes No 4. Does the care provider have a Medicaid identification number? Yes No 5. Is the care provider a primary care physician? Yes No 6. Is the care provider hospital-based operating solely in a hospital? Yes No 7. Add hospital affiliations (hospital names): 8. Remove these hospital affiliations (hospital names): 9. Is the care provider accepting new patients? Yes No SR11830268 1
10. Care provider s email: Not applicable 11. Care provider s website: Not applicable 12. Is the care provider an Indian Health Service provider? Yes No 13. National Provider Identifier (NPI) Please refer to Section III for details about NPI requirements. Is the practitioner an atypical provider? Yes NPI is not required. No If you choose No, an NPI is required. Please complete the following information: NPI: NPI Taxonomy Code: NPI Issue Date (MM/DD/YYYY): Basis for NPI: NPI Level of Information 14. Care provider s primary specialty: a. Is the care provider board certified for this specialty? Yes No 15. Care provider s secondary/sub-specialty: Not available 16. Does the care provider have expertise in certain specialty areas? (examples: HIV, chronic illness, etc.) Yes: No 17. Care provider s primary degree: Secondary degree: 18. Care provider s state licenses (please add dates as MM/DD/YYYY): State: License: Effective Date: Expiration Date: State: License: Effective Date: Expiration Date: 19. Is the care provider a mid-level provider? If yes, list the name of the supervising physician. Yes: No 20. Does the care provider have a Drug Enforcement Administration (DEA) registration number? Yes: Expiration Date (MM/DD/YYYY): No Questions 21-23 are required when adding UnitedHealthcare Military & Veterans care providers: 21. Council for Affordable Quality Healthcare (CAQH) ID or Social Security number (SSN): 22. Does the care provider accept VA (Department of Veterans Affairs)? Yes No 23. Does the care provider accept CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs)? Yes No Section II Updates: Taxpayer Identification Number, Addresses, Contact Information Taxpayer Identification Number (TIN) Updates Updating the TIN may require also updating the corresponding address. Please make the address changes on this form as needed and attach a copy of the W9 for TIN additions and changes. Change a TIN New TIN: Old TIN: SR11830268 2
Group or organization associated with this care provider/tin Add a TIN: Group or organization associated with this care provider/tin Terminate a TIN: Telephone or Fax Number Update Provide any additional telephone or fax updates on a separate roster and include the following information. Publish practice location address phone number in the care provider directory. Yes No If you choose not to display the phone number, one of the following reasons must apply: Care provider is not active due to taking an extended leave of absence. Care provider is in the process of being removed from the UnitedHealthcare network. Care provider is under investigation for fraud, licensure or quality issues. Address associated with this update: Billing Practice Location Mailing Credentialing This is a phone: change add only termination only Add phone: Delete phone: This is a fax: change add only termination only Add fax: Delete fax: Address Updates Delete Address Provide any additional addresses on a separate roster and include the following required information. Address type: Billing Practice Location Mailing Credentialing Add Billing, Mailing or Credentialing Address Provide any additional addresses on a separate roster and include the following required information. Address type: Billing Mailing Credentialing Billing address correspondence: Primary Secondary None Practice Location Address: Add New Address Update Current Address SR11830268 3
Provide any additional addresses on a separate roster and include the following required information. Phone: Fax: For this practice location address, all of the following information is required: 1. This is the primary practice location address. Yes No 2. Publish the practice location address in the care provider directory. Yes No a. If you choose not to display the address, one of the following reasons must apply: Care provider is not active due to taking an extended leave of absence. Care provider is in the process of being removed from the UnitedHealthcare network. Care provider is under investigation for fraud, licensure or quality issues. 3. The practice location address, for correspondence purposes, is: Primary Secondary None 4. NPI associated with the practice location address (not required for atypical providers): Not applicable 5. NPI issue date associated with the practice location address: 6. NPI taxonomy code associated with the practice location address: 7. Medicaid identification number associated with this practice location address: 8. *Primary specialty associated with this practice location address: 9. Additional specialty associated with this practice location address: a. Additional specialty effective date: 10. Area of expertise associated with this location address (if applicable): 11. Practice location address office hours: Mon: Tues: Wed: Thurs: Fri: Sat: Sun: 12. Is this location handicap accessible? Yes No 13. Languages associated with this practice location address: Spoken by: Practitioner Written by: Practitioner Staff Staff 14. Patient age restrictions associated with this practice location (ages in numerals; 0 99): These following questions are required for UnitedHealthcare Military & Veterans care providers: 15. Is the care provider a primary care manager (PCM) for TRICARE Prime beneficiaries at the practice location address? Yes No 16. How many TRICARE beneficiaries will this care provider accept at the practice location address? SR11830268 4
Section III - Definitions A primary care manager (PCM) is identified as a care provider or mid-level practitioner who meets the following criteria: practices in one of the following areas: internal medicine physicians, family practitioners, pediatricians, general practitioners, obstetricians, gynecologists, physician assistants, or nurse practitioners; and has one place of service location within a TRICARE Prime Service Area. A care provider signs a contractual agreement to become a PCM and must follow TRICARE procedures and requirements for obtaining specialty referrals and prior authorizations for nonemergency inpatient and certain outpatient services. UnitedHealthcare Military & Veterans care providers only. The National Provider Identifier (NPI) is a federal requirement; however, atypical providers are not required to have an NPI. Atypical providers are individuals and organizations that furnish non-traditional services that are indirectly health care related, such as taxi service, home and vehicle modifications, habilitation and respite services. Basis for NPI C Entity whose name is on the W-9 D Department L License P Place of service address T Tax ID number and provider name X Taxonomy O Other M Name NPI Level of Information Tax ID and name filed on the W-9: Legal owner of TIN - does not bill for medical services. Indicate if this number is a SSN or TIN. Department name: If the organization or sub-part was enumerated on the basis of a particular department, provide the department name that the NPI was based on, and designate this with a D in the Basis for NPI field. Insert the department name in the NPI Level of Information field. License number and state or state code: If the organization or sub-part was enumerated by license, provide the state or state code and license number that the NPI was based on, and designate this with an L in the Basis for NPI field. Insert the license number and state or state code in the Level of Information field. Place of service address (street, city, state, ZIP+4) If the organization was enumerated by place of service address, provide the street address that the NPI was based on and designate this with a P in the Basis for NPI field. Insert the place of service address in the NPI Level of Information field. List NPI for each group/organization place of service Tax ID and provider name where the care provider is not the same as on the W-9, but bills with this TIN. Indicate whether the Tax ID is an SSN or TIN. National Uniform Claim Committee (NUCC) Taxonomy Code: If the organization or sub-part was enumerated by a NUCC Taxonomy code, provide the taxonomy code that the NPI was based on and designate this with an X in the Basis for NPI field. Place the NUCC Taxonomy Code in the NPI Level of Information field. Any other basis for the NPI: Provide any other basis for NPI in the Basis for NPI field and designate as O, with a description of the basis for that NPI in the NPI Level of Information field. Insert the name of the physician or allied health professional in the NPI Level of Information field. SR11830268 5
Section IV Sign and Submit Please submit your completed form to the appropriate email address from the following list. *Person completing this form: *Telephone: ( ) *Office Contact: *Date: UnitedHealthcare and its affiliates/alliances UnitedHealthcare (including UnitedHealthcare Community Plan, UnitedHealthcare Military & Veterans) UnitedHealthcare West (including UnitedHealthcare Community Plan, UnitedHealthcare Military & Veterans) States (if applicable) AL, AK, AR, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, NE, NH, NM, NV, OH, PA, PR, RI, SC, SD, TN, Upstate NY, Empire Health Plans (Markets 99309, 99310, 99318), UT, VA, VI, VT, WI, WV, WY AZ, CA, CO, OK, OR, TX, WA E-mail address hpdemo@uhc.com phshpdemo@uhc.com UnitedHealthcare/Oxford CT, NJ, NY (excludes Upstate NY and Empire Health Plans) ox_hpdemo@uhc.com Harvard Pilgrim Health Care Medica lb_hpdemo@uhc.com UnitedHealthcare Plan of the River Valley Inc. Neighborhood Health Partnership jdhpdemo@uhc.com Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. TRICARE West Region Customer Service: 877-988-9378 (WEST) UHCMilitaryWest.com TRICARE is a registered trademark of the Defense Health Agency. All rights reserved. SR11830268 6