news - Kaiser Permanente › info_assets › ... · 2. MRI: Wide Bore and Open MRI Revision date: 12/28/2017 • Updated section II, A, number 1, 2 and 4: Referral procedure for members

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Digital membership cards now with photo

Medical Coverage Policy update II - 2017

Pharmacy benefit updates effective January 1st, 2018

Pharmaceutical management information and updates

Provider access to health education materials

Behavioral health providers expanded

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FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE

Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., with the Mid-Atlantic Permanente Medical Group, P.C. Website: providers.kaiserpermanente.org/mas

DECEMBER 2017

Medicare AdvantageWe are pleased to announce that effective January 1, 2018 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. will participate as a Medicare Advantage MCO in DC and parts of MD (Harford, Baltimore, Baltimore City,

Howard, Montgomery, Anne Arundel, and Prince George’s counties). We will also still have the Kaiser Permanente Medicare Plus plan for our Cost members.

Kaiser Permanente Medicare Advantage Participating Providers will play an integral role in the care and coordination of services for Medicare Advantage members. It is important that these providers are familiar with these responsibilities and the differences between our Medicare plans when providing and/or coordinating services to our members.

The new Kaiser Permanente Medicare Advantage member ID card will have Medicare Advantage identified in the upper right corner. Please verify benefits by contacting Kaiser Permanente Member Services at (888) 225-7202 or verifying online via our Kaiser Permanente Online Affiliate website at providers.kp.org/mas.

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One key point to keep in mind is that Medicare Advantage members will have Kaiser Permanente as their primary insurance carrier. This means that claims should be submitted to Kaiser Permanente as primary. Medicare Advantage claims should be billed to:

Mid-Atlantic Claims AdministrationKaiser PermanentePO Box 371860Denver, CO 80237-9998

There is no change to the referral and authorization request requirements. Referrals and authorizations will still need to be obtained for specialty care services, hospitalizations, and other facility services.

Providers may continue to request authorizations from our Utilization Management Operations Center by phone at (800) 810-4766 or by fax at (800) 660-2019.

To help support our Medicare Advantage Participating Providers with understanding their responsibilities to our members, we have developed training information specifically for Medicare Advantage that will be available in the near future. When that information becomes available providers may log on to our Community Provider Website at providers.kp.org/mas to access the on-line Medicare Advantage Participating Provider Training.

Digital membership cards now with photoLast year, Kaiser Permanente launched the digital membership card and now we have added the feature of a member photo. The photo digital membership card is an electronic version of the physical membership card that eligible* Kaiser Permanente members can access via the Kaiser Permanente app on their smartphones.

The photo digital membership card does not replace the physical membership card, which we will continue to distribute and accept but can be used in lieu of the physical card.

Members will be able to use the photo digital membership card for services such as checking in for appointments and prescription pickup at Kaiser Permanente and participating affiliate facilities. Members also will have the ability to display

photo digital membership cards for their family members and dependents on their mobile devices,

and can email a copy of their digital membership cards to participating providers.

When a member presents for service with a photo digital membership card, your check-in procedure should remain the same. Your staff should validate membership as they currently do. Remember to record the medical record number and to ask the member to show a photo ID if no photo is displayed on the digital membership card.

If you should have any questions about the new photo digital membership card, please contact Provider Relations at (877) 806-7470 or email us at [email protected].

* Until further notice, the digital membership card is not available to members in certain plans including Medicare, Medicaid, out-of-area, Flexible Choice Three Tier Point-of-Service, and FAMIS.

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Medical Coverage Policy updateThe following Kaiser Permanente Mid-Atlantic Medical Coverage Policies (MCPs) were approved in December 2017.

We develop MCPs in collaboration with specialty service chiefs and clinical subject matter experts. MCPs specify clinical criteria supported by current peer reviewed literature and are used to guide decisions related to request for health care services such as devices, drugs, and procedures. The policies are reviewed and updated annually, reviewed for approval by the Regional Utilization Management Committee (RUMC), and are periodically reviewed by regulatory and accrediting agencies. Except where noted, our MCPs are primarily applicable only to commercial members.

A. NEW OR UPDATED MEDICAL COVERAGE POLICIES

1. Vitiligo Treatment Revision date: 12/28/2017• References were updated

2. MRI: Wide Bore and Open MRIRevision date: 12/28/2017• Updated section II, A, number 1, 2 and

4: Referral procedure for members with subjective claustrophobia

• References were updated.

3. Home PhototherapyRevision date: 12/28/2017• Section III, A: Home phototherapy treatment

clinical indications are updated.• Section III, B: Clinical indications for referral.

Physician’s supervision for home phototherapy, in office visits edited from three months to every 3 to 6 months.

• References were updated

4. NICU – Neonatal Care Admission and Discharge• Disclaimer on MCG Guidelines: NICU

Admission and Discharge replaced with a verbiage which states that the content of the NICU MCP may differ from MCG Care Guideline standards which has not been reviewed or approved by MCG Health, LLC.

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B. TRANSPLANT PATIENT SELECTION CRITERIA

1. Mechanical circulating device

2. Transplant - heart

3. Transplant - heart-lung

4. Transplant - kidney

5. Transplant - pancreas + pancreas/kidney

6. Transplant - simultaneous pancreas/kidney

Access to MCPs is only two clicks away in Health Connect. Medical Coverage Policies can be accessed through the KP Clinical Library by using this web link: https://clm.kp.org/wps/portal/cl/MAS/search_iframe?query=medical+coverage+policy&x=0&y=0.

Click on the Clinical Library section on the right side of the KPHC Home page and then type in “medical coverage policy” in the search box. All medical coverage policies will be displayed.

Please contact the Utilization Management Operations Center (UMOC) at (800) 810-4766 to receive a copy of the UM guideline or criteria related to a referral.

All Practitioners have the opportunity to discuss any non-behavioral health and or/behavioral health Utilization Management (UM) medical necessity denial (adverse) decisions with a Kaiser Permanente Physician reviewer (UM Physicians).

If you have clinical questions on use of our criteria, please feel free to contact:

Claudia Donovan M.D. Physician Referral Reviewer [email protected]

If you have administrative questions on accessing or using our criteria, please contact:

Marisa R Dionisio, [email protected](301) 816-6689

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Pharmacy benefit updates effective January 1st, 2018Effective January 1, 2018, several changes are being made to Kaiser Permanente Prescription Drug Benefits. This memo will provide detailed information on these changes.

Medicare Part D Prior Authorization UpdateMedicare continues to require Part D plans to implement utilization management controls, such as prior authorizations (PAs), to determine how pharmacy claims should be paid by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare.

Medicare requires that Part D drugs are prescribed only for medically acceptable indications (FDA-approved and off-label indications outlined in the CMS-approved compendia). To ensure compliance with Medicare mandates, Conditional PAs will be placed on the additional drugs listed in the chart below starting January 1, 2018: These select medications will only be covered under Part D benefit when:• Prescribed for an FDA-approved indication or

outlined in the CMS-approved compendia, and

• An associated diagnosis is documented in HealthConnect or written on the prescription.

These drugs will NOT be covered under the Part D drug benefit and patient will be charged the full member rate if one of the above criteria is not met.

Before this change in coverage occurs, please review your MPD patients that are currently on a medication with a conditional PA for a non-FDA approved indication and consider alternative therapy. When prescribing, please be sure to link the diagnosis (using ICD codes), in HealthConnect or include it with the prescription order. Refer to page 6 for a list of drugs with existing Medicare Conditional Part D PAs and to the online posing of 2018 MAS Medicare Part D formulary for a complete list of drugs with PA requirement https://healthy.kaiserpermanente.org/static/health/en-us/pdfs/nat/Medicare_2018_NAT/comprehensive_formulary.pdf

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Selected drugs withConditional PAs

FDA-approved indications (Medicare will not cover off-label uses unless noted in approved compendia)

Buprenorphine-naloxone (Zubsolv, Suboxone, Bunavail); buprenorphine sublingual tablets and filmMPD: Generic Tier 2,Non-Preferred Brand Tier 4

Indicated for the maintenance treatment of opioid dependence.

Eteplirsen (Exondys 51) injectionMPD: Specialty Tier 5

Indicated for treatment of Duchenne Muscular Dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping.

Macitentan (Opsumit) capsulesMPD: Specialty Tier 5

Indicated for treatment of Pulmonary Arterial Hypertension (PAH, WHO Group I) to delay disease progression.

Natalizumab (Tysabri) injectionMPD: Specialty Tier 5

Indicated for treatment of: • Multiple Sclerosis (MS): as monotherapy for the treatment of patients

with relapsing forms of multiple sclerosis. Tysabri increases the risk of PML. When initiating and continuing treatment with Tysabri, physicians should consider whether the expected benefit of Tysabri is sufficient to offset this risk. See important information regarding the risk of PML with Tysabri I.

• Crohn’s Disease (CD): for inducing and maintaining clinical response and remission in adult patients with moderately to severely active Crohn’s disease with evidence of inflammation who have had an inadequate response to, or are unable to tolerate, conventional CD therapies and inhibitors of TNF-α.

Important Limitations: • In CD, Tysabri should not be used in combination with

immunosuppressants or inhibitors of TNF-α.

Riociguat (Adempas) tabletsMPD: Specialty Tier 5

Indicated for treatment of adults with: • Persistent/recurrent Chronic Thromboembolic Pulmonary Hypertension

(CTEPH) (WHO Group 4) after surgical treatment or inoperable CTEPH to improve exercise capacity and WHO functional class.

• Pulmonary Arterial Hypertension (PAH) (WHO Group 1) to improve exercise capacity, improve WHO functional class and to delay clinical worsening.

Treprostinil sodium (Remodulin) injectionMPD: Specialty Tier 5

Indicated for treatment of pulmonary arterial hypertension (PAH, WHO Group 1) to diminish symptoms associated with exercise. Studies establishing effectiveness included patients with NYHA Functional Class II-IV symptoms and etiologies of idiopathic or heritable PAH (58%), PAH associated with congenital systemic-to-pulmonary shunts (23%), or PAH associated with connective tissue diseases (19%). Patients who require transition from Flolan®, to reduce the rate of clinical deterioration. The risks and benefits of each drug should be carefully considered prior to transition.

Tasimelteon (Hetlioz) capsulesMPD: Specialty Tier 5

Indicated for treatment of non-24-hour sleep-wake disorder (non-24).

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Medicare Part D Drug Utilization Review (DUR) and Management at Point Of Sales (POS) Opioid morphine equivalent dose: Effective January 1st, Morphine Equivalent Dose threshold for opioid prescriptions for all Medicare members will be set at 90 mg MME (MED). This is a change from the current threshold of 100 mg MME. This change might result in additional opioid prescription claims at point of sale requiring drug utilization review and therapy modification or use of POS overrides. POS overrides are allowed when there is a documented review and approval by the prescriber and/or pharmacist.

Medicare Part D tiering exception

Per CMS guidelines, when a drug tier exception is approved, Kaiser Permanente must provide coverage for the drug in the higher cost-sharing tier at the cost-sharing level that applies to the drug in the lower cost-sharing tier.

Effective January 1st, members may request a tier exception for drugs on Tiers 2, 3, and 4 as follows: • Tier 2 Generic drug at a Tier 1 Preferred Generic

cost share. • Tier 3 Preferred Brand at a Tier 2 Generic cost

share. *new for 2018*

• Tier 4 Non-Preferred Brand drug at a Tier 3 Preferred Brand cost share.

• Tier 4 Non-Preferred Brand drug at a Tier 2 Generic cost share. *new for 2018*

Tier 5 Specialty drugs are not eligible for any tier exceptions and Tiers 3 and 4 are not eligible for a Tier 1 Preferred Generic tier exception.

Kaiser Permanente Providers will continue to determine medical necessity for tiering exception required and provide supporting statement that indicates whether the preferred drug is not as effective as the requested non-preferred drug or patient would have adverse effects.

Medicare Advantage in KPMAS Region

Effective January 1, 2018 KPMAS region is beginning the conversion from a Medicare Cost Contract, fee for service model, to Medicare Advantage contract, risk model. During calendar year 2018 and until the region conversion to Medicare Advantage takes place, the region will serve both Medicare cost and risk members. Approximately 11,200 current Kaiser Permanente Medicare Cost members will transition to Medicare Advantage.

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Medicare Advantage, also called “Part C” – includes both Part A (Hospital Insurance) and Part B (Medical Insurance). It also includes Part D drug coverage. Covered services in Medicare Advantage Plans are:• All Medicare services. • Extra coverage, like vision, hearing, dental, and/

or health and wellness programs may be offered• In-network provider services only

This change will allow KPMAS to offer competitive Medicare Advantage products in the Mid-Atlantic market, will align KPMAS with other Kaiser Permanente regions and streamline processes. Please keep in mind the following as the region

begins transitioning to Medicare Advantage:• Annual enrollment begins October 2017• Coverage will begin January 1, 2018• Complete Conversion to Medicare Advantage

goal is January 1, 2020

Commercial benefit updates

Contraceptives: Maryland and Virginia adopted new legislation that requires health plans to cover greater than 90 days of contraceptives on one dispense. The new coverage will take effect on January 1st, 2018 or upon group renewal of coverage. This change applies to all plans, except VA Medicaid and Medicare plans. Please refer to chart below for details.

Contraceptive commercial benefit update CY 2018

Jurisdiction Benefit applies to Days supply allowed Copays

Maryland/Federal (new for 2018)

All ACA mandated plans with $0 copay for contraceptives

Up to a 6-month supply $0 or when copays other than $ 0 applies, the member will pay the corresponding 90Dx2 or x4 copay.

Virginia (new for 2018) All plans Up to a 12-month supply

DC All plans Up to a 12-month supply

Diabetic test strips: Effective January 1st ,2018 or based on group renewal, diabetic test strips will be at $0 copay for all Maryland jurisdiction groups. Only members with High Deductible Health Plans (HDHP), will be required to pay towards their deductible before paying the $0 copay for diabetic test strips.

Preventative statins Effective January 1st, 2018 all benefits with preventative OTC coverage, will cover low to moderate dose statins at $0 copay for members meeting specific criteria for the prevention of cardiovascular disease (CVD) events.

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Preventive statins criteria

Age 40-75 years 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking

Calculated 10 years risk of a cardiovascular event of 10% or greater

Legend Rx available as OTC exclusions: Applicable to all commercial plans, effective January 1, 2018 or upon renewal, legend/Rx products listed below will be excluded from prescription benefit coverage due to an OTC equivalent product being available for sale. Members that have received any of the below

medications with refills remaining will receive a letter notifying them of this change. Members can continue to receive the legend/rx products but will pay the cash price.

OTC equivalents are not available through mail order.

Legend/Rx available as OTC coverage changes CY 2018

Allegra (fexofenadine) tablet, liquid Flonase (fluticasone) nasal spray

Oxytrol (oxybutynin) transdermal patches

Rhinocort (budesonide) nasal spray

Allegra-D (fexofenadine-pseduoephedrine) tablet

Nasacort (triamcinolone acetonide) nasal spray

Prevacid (lansoprazole) capsule

Xyzal (levocetrizine HCl) tablets, solution

Differin (adapalene) 0.1% gel Nexium (esomeprazole) capsule

Prilosec and Zegerid (omeprazole) capsule

Zantac (ranitidine) tablet

Please email questions related to 2018 benefit updates to MAS pharmacy benefit team: [email protected].

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Appendix 1-Medicare Conditional Part D prior authorization drugs

abobotulinumtoxinA (Dysport) incobotulinum toxin A (Xeomin) somatropin Products:

alirocumab (Praluent) ivacaftor (Kalydeco) Genotropin

apremilast (Otezla) ledipasvir-sofosbuvir (Harvoni) Humatrope

armodafinil (Nuvigil) lidocaine (Lidoderm) patch Norditropin

baclofen (Gaboflen/Lioresal) IT lomitapide (Juxtapid) Nutropin

buprenorphine HCl sublingual tablets meperidine (Demerol) Nutropin AQ

buprenorphine HCl-naloxone (Zubsolv) sublingual tablets

methamphetamine (Desoxyn) Omnitrope

buprenorphine HCl-naloxone (Suboxone) sublingual film

macitentan (Opsumit) Saizen

buprenorphine HCl-naloxone (Bunavail) buccal film

mipomersen (Kynamro) Serostim

carisoprodol products modafinil (Provigil) Zorbtive

chorionic gonadotropin natalizumab (Tysabri) Tev Tropin

clomiphene ombitasvir/paritaprevir/ritonavir (Technivie)

tadalafil (Adcirca/Cialis)

corticotropin (H.P. Acthar) gel ombitasvir/paritaprevir/ritonavir & dasabuvir (Viekira Pak & XR)

tasimelteon (Hetlioz)

cyclobenzaprine IR and ER onabotulinum toxin A (Botox) tazarotene (Tazorac)

daclatasvir (Daklinza) pirfenidone (Esbriet) teriflunomide (Aubagio)

diclofenac (Flector) patch progesterone (Crinone) treprostinil (Remodulin)

dronabinol (Marinol, Syndros) riociguat (Adempas) tretinoin (Retin-A/Avita/Tretin-X)

elbasvir/grazoprevir (Zepatier) simeprevir (Olysio) transmucosal immediate-release fentanyl (TIRF)

evolocumab (Repatha) sofosbuvir (Sovaldi) ustekinumab (Stelara)

glecaprevir-pibrentasvir (Mavyret) sofosbuvir-velpatasvir (Epclusa)

immune globulin (Gamastan S/D, Hyqvia) sofosbuvir-velpatasvir-voxilaprvir (Vosevi)

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Pharmaceutical management information and updatesThe KPMAS Regional Pharmacy & Therapeutics (P&T) Committee approves drug formularies for all lines of business, Commercial, Marketplace/Exchange, Medicare, Virginia Medicaid and MD HealthChoice (Medicaid).

The Regional P&T Committee, with expert guidance from various medical specialties, evaluates, appraises, and selects from available medications those considered to be the most appropriate for patient care and general use within the region. The purpose of the formulary is to promote rational, safe, and cost-effective drug use.

The formularies are updated monthly with additions and/or deletions approved by the Regional P&T Committee. The most recent information on drug formulary updates or changes can be accessed via the online Community Provider Portal for affiliated practitioners available at providers.kaiserpermanente.org/html/cpp_mas/formulary.html. To view the P&T Committee decisions, the KPMAS formularies and pharmacy benefit-related memos, you will be redirected to the KPMAS Clinical Library, a secured network, and asked to sign in and/or register for access.

A printed copy of each drug formulary is available upon request from the Provider Relations department, which can be contacted via email at [email protected].

To locate the P&T Committee decisions, the KPMAS formularies and pharmacy benefit-related memos on the Community Provider Portal, please follow the appropriate web path:

P&T Committee decisions

Patient Care Resources

aDrug

Information

aPharmacy and Therapeutics Committee decisions

Electronic copies of KPMAS formularies

Patient Care Resources

aDrug

Information

a Formulary

Pharmacy benefit memos

Patient Care Resources

aDrug

Information

a Formulary

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Provider access to health education materialsKaiser Permanente physicians and network providers have access to all health education materials to provide to patients as part of the After Visit Summary or to supplement discussion from patient visit.

Content can be viewed through the centralized internal “clinical library” which is an electronic inventory of health education information that can be used for all visit types. Health education content is also embedded into KP HealthConnect for inclusion in member After Visit Summary or sent via secure messaging. For health education programs, providers can:

• Refer or direct book members into health education programs through eConsult system

• Provide members with information on how to self-register through KP HealthConnect, After Visit Summary, or hard copy flyers

Additional information on health education programs, tools, and resources is available by:

• Visiting kp.org/healthyliving• Contacting the Health Education automated line

(301) 816-6565 or (800) 444-6696 (toll free)

Utilization Management Affirmation Statement Kaiser Permanente practitioners and health care professionals make decisions about which care and services are provided based on the member’s clinical needs, the appropriateness of care and service, and existence of health plan coverage. Kaiser Permanente does not make decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. The health plan does not specifically reward, hire, promote, or terminate practitioners or other individuals for issuing denials of coverage or benefits or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care and services or result in underutilization. In order to maintain and improve the health of our members, all practitioners and health professionals should be especially diligent in identifying any potential underutilization of care or service.

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Behavioral health providers expanded As part of our commitment to our members, we continually strive to provide better access to care and integration services within Kaiser Permanente Medical Centers. Over the past few years we’ve expanded the number of behavioral health providers, with a wide range of expertise within Kaiser Permanente. We’ve also extended service hours in to the evening at many of our facilities to better accommodate our members.

To better care for our members, we have expanded behavioral health programs, offered across the region, within our medical centers. We have Intensive Outpatient Programs (IOP) designed to deliver a better continuum of care for discharged patients. We can schedule 24/7 evaluation and psychiatric consultation in our Clinical Decision Units (CDU’s) or Urgent appointments by contacting our Call Center at (800) 777-7904.

Members referred to a Kaiser Permanente behavioral health provider experience the benefits of coordinated care with the co-location of primary care and specialty care services in one place in our behavioral health locations; all connected through our electronic medical record system. Members registered on kp.org can also e-mail their behavioral health provider’s office, view most laboratory results, and refill most prescriptions on-line.

Note to Network Behavioral Health Providers: After an initial consultation, if you determine a Kaiser Permanente Member requires follow-up care you will need to send via fax a proposed treatment plan for the patient to Kaiser Permanente Behavioral Health Utilization Management at (855) 414-1703.

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Kaiser Permanente ClaimsConnectOur new claims processing system, Kaiser Permanente ClaimsConnect, has been up and running since February 8, 2016 and claims are now being processed by our centralized National Claims Administration (NCA).

Here are a few helpful tips to ensure that your claims are efficiently processed and paid:

• For paper claims, use industry standard pre-printed RED claim forms. CMS-1500 (02-12) version for professional claims and UB-04 (CMS-1450) for institutional claims. Color photo copies or copies printed on color printers are not acceptable as the red color and the scaling of the image result in poor quality of the data on the form.

• Our National Claims processing center receives claims for five different Kaiser Permanente regions and each region has a unique PO Box. Please make sure you send your claim to the correct PO Box for Mid-Atlantic States.

Kaiser PermanenteMid-Atlantic Claims AdministrationP.O. Box 371860Denver, CO 80237-9998

• The best method for claim submission is electronic. It is more efficient and faster than paper claim processing and you will receive a claim acceptance through your clearinghouse. Use the 837P and 837I format. Our electronic payor ID has not changed, it is: 52095.

Disputes and appeals should also be sent to the same claims address as above. They may also be faxed to (855) 414-2622.

Keeping the Provider Directory up to datePlease use the sample letter format on the next page to update us with any changes you may have through out the year. It is very important that we have the most accurate information when we pull our data for the directory.

Changes may be made by fax to: (855) 414-2623, email [email protected], or by mail:

Kaiser Foundation Health Plan of The Mid-Atlantic States, Inc. Provider Relations; Flr 2 East 2101 East Jefferson St. Rockville, MD 20852

If you would like to request a provider directory please contact Member Services:

• For within the Washington, D.C., metro area call (301) 468-6000, (301) 879-6380 TTY

• All other areas outside of Washington, D.C., metro area call (877) 777-7902, (800) 700-4901 TTY.

Member Services Provider Claims Line

Kaiser Permanente Member Services has a dedicated phone line for providers with claims inquiries and concerns. Providers may call (866) 876-5934 Monday through Friday from 9 am to 5 pm.

A Member Services representative will be able to assist you with the following:• Claims status• Claims reprocessing• Tracking a claim payment if it is past 30 days• Copies of EOPs

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Company Logo or Letterhead

<<Date>>

Requestor: Requestor’s Correspondence Address:Requestor’s Phone #:Email:Tax ID#:Effective date of change(s):

Reason for the request:

Address change (Specify if practice location or billing address is changing)• Specify if adding or deleting address• Include old and new demographic information when sending request • (Street Address, City, State, Zip, Phone, Fax and NPI)• Billing/Payment Address• Management Correspondence Address (include Phone & Fax Number)

Adding a provider to an existing group or deleting a provider from an existing group• Specify if adding or deleting provider• Include the below listed information if adding or deleting a provider:

» First Name, Middle initial, and Last Name » Gender » Date of Birth » Title (MD, CRP, CRNP, PA etc.) » NPI # » CAQH # » UPIN or SSN » Medicare # » Medicaid Participation State(s) » Medicaid # » Primary Specialty (include secondary specialty if applicable) » Practice location (include Phone & Fax Number) » Billing/Payment Address (include W-9) » Management Correspondence Address (include Phone & Fax Number) » Hospital Privileges » Foreign Languages » Effective date

Changing the Tax Identification Number and/or the name of an existing group • Include old and new Tax ID Number and/or group name• Include effective date of the new Tax ID Number and/or group name• Include a signed and dated copy of the new W-9• Billing/Payment Address• Management Correspondence Address (include Phone & Fax Number)

**Email your letter to the Provider Relations Department at [email protected] or fax to (855) 414-2623.

The Mid-Atlantic Permanente Medical Group, P.C.2101 E. Jefferson StreetRockville, MD 20852

Presorted Standard

U.S. Postage

PAID

Permit #4297

Suburban, MD