UPMC Health Plan | Providers

As a participating provider, you can now submit changes to your profile online instead of submitting on paper. The following changes may be made through the online request form:

Behavioral health providers, please contact Community Care to submit information changes.

The information entered into this form is subject for review by UPMC Health Plan. Submitting this information change form will not automatically upload to our system but will reviewed and any questions will be addressed before the change can be made.

*Required Information

Date:

Name of Group or Provider:

PCP	Ob-Gyn	Specialist	Ancillary
Chiropractor	Dental PPO Provider	Vision PPO Provider

Contact Name:*

Provider Number :

Phone:*

E-mail:

Please choose the options you wish to make changes to. The appropriate fields
will then open, allowing you to complete your change request.

Add/Remove a Provider to/from a Practice or Group
Add or Remove an Office Location
Office or Provider Information Change
Change Pay to Address or Tax ID
Change in Hospital Privileges
Close/Reopen Panel
Add/Drop Products (Applies to Medical Network Providers Only)
Provider Termination
Other Information (Notes)

Add/Remove a Provider to/from a Practice or Group

If you are adding or removing a provider from multiple office locations, please enter the primary location here and provide additional locations in the "Additional information (Notes)" section of the form.

Add a Provider to a Practice or Group Remove a Provider from a Practice or Group

Provider Name:
Group/Practice Name :
Tax ID:
Business Address 1:
Business Address 2:
Suite:
City:
State:
Zip Code:
Phone:
Fax:

Effective Date :	Required

Add or Remove an Office Location

Add an Office Location
Remove an Office Location

*Billing location cannot be removed here. To change your billing location, please complete the section "Change Pay to Address or Tax ID."

Office/Location Name:

Phone Number:

Fax Number:

Tax ID:

Address Line 1:

Address Line 2:

Suite:

City:

Zip:

Handicap Accessible:

Yes
No


Office Hours:	Open	Lunch	Closed
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Effective Date :

Required

Provider/Office Information Change

Office/Location Name to Change:

Old Phone Number:

New Phone Number:

Old NPI Number:

New NPI Number:

Handicap Accessible:

Yes
No

Name Change:

Provider
Practice

Name to Remove:

Name to Add:


New Hours:	Open	Lunch	Closed
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Effective Date :

Required


Change Pay to Address or Tax ID

A group billing address must be the same for every doctor/office under that tax ID. The billing address can only be changed if it is for the whole group with that same tax ID.
*This form will not change the practice location. To update the practice location, please complete the section "Add or Remove Office Location."

Billing Address Change Tax ID Change (Submit W9 form below) Both Billing Address and Tax ID Change

Effective Date:	Required

Old Billing Address:

New Billing Information
Business Address 1:
Business Address 2:
Suite:
City:
State:
Zip Code:
Phone:
Fax:

Download Tax ID Form (must be faxed to UPMC Health Plan — 412-454-8225)


Change in Hospital Privileges

Changing the hospital affiliation of the doctor or group may affect the products they can provide.

Affiliations to Remove
Hospital:
Privileges:

Hospital:
Privileges:

Hospital:
Privileges:

Affiliations to Add
Hospital:
Privileges:

Hospital:
Privileges:

Hospital:
Privileges:

If you are not able to complete the online form, please complete and fax the below forms to UPMC Health Plan at 412-454-8225.