NOTIFICATION OF CHANGE IN PRACTICE STATUS
Providers must immediately notify the Carelon Engagement Center in writing, to the attention of the Network Management Department, upon the occurrence of any of the following:
- Change of address, name change or merger, and/or new tax identification number. Please use either the “Address Update Form” or the “Request for Taxpayer Identification Number Form” when submitting the change. These forms may also be faxed to 1-855-541-5211.
- Revocation, suspension, restriction, termination, or voluntary relinquishment of any of the licenses, authorizations, or accreditations required by the Carelon agreement
- Any legal action pending for professional negligence which may reasonably be considered to be a material loss contingency, and the final disposition of the action
- Any indictment, arrest, or conviction for a felony or for any criminal charge related to an individual’s or a facility’s professional practice
- Any lapse or material change in professional liability insurance coverage;
- Restriction, suspension, revocation or voluntary relinquishment of medical staff membership or clinical privileges at any healthcare facility
- Any condition that results in temporary closure of a facility or office; or
- Outbreak of a serious communicable disease
Carelon recognizes that members have a basic right to privacy of their personal information and records. Access to member information lies solely with the member except in the case of a parent or guardian with legal custody of a minor child, or a person with legal authority to act on behalf of an adult or emancipated minor in making decisions related to health care.