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On Feb. 21, 2024, Change Healthcare experienced a cybersecurity incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare’s website or reach out to their contact center: 1-866-262-5342.

Demographic Change

Note: If provider prefers to update demographic information by fax or email, use the Provider Change form on our Contracting & Credentialing Forms page.

What do you want to do? required *

Service Location Address

Update Requested By

Practitioner Current Name

Practitioner New Name

Update Requested By

Practitioner Name

Update Requested By

Practitioner Name

Service Location Address

New Provider Office Hours

Update Requested By

Service Location Address

Service Location Office Hours

Update Requested By

Choose All Applicable Networks required *
Select subject required *

*If submitting for multiple products, please indicate applicable products in the comment section.*

If submitting for specific WellCare product(s), indicate applicable products in Comments section

If multiple practitioners' provider updates are needed, please download the Meridian Roster Template and attach it in the upload field. All roster fields are required.

Meridian Roster Template (Excel)
(Roster template revised 02/04/2022)

1. Providers must be IMPACT approved for any Medicaid, YouthCare, or Dual product, and Medicaid numbers must be supplied

2. Prior to Ambetter and Medicare submissions:

  • Validate CAQH is current and accessible to the health plan for all practitioners
  • NOTE: CMS does not allow more than 20 locations per practitioner

Update Requested By

 

This form will send your message to Iowa Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Iowa Total Care through email, you accept associated risks. Iowa Total Care does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.