Avera Health Plans Helpful Forms
Provider Change Form
Avera Health Plans participating providers should submit all changes that occur at their practice to Avera Health Plans Network Services. We recommend you complete the attached Provider Change Form (fill-able form in Microsoft Word) and also include an updated W-9 Form for our records.
PDF version of the Provider Change Form
Examples of changes that require notification are:
- New Tax Identification Number (TIN)
A change in TIN requires a new provider contract; contact Network Services at the phone number listed below.
- Practice Name Change
- Address Change (Physical or Billing)
- Phone/Fax Number Change
- Provider(s) Leaving Practice
Please include termination date.
Please return your information to:
Avera Health Plans
Attn: Network Services
3816 S Elmwood Avenue, Suite 100
Sioux Falls, SD 57105-6538
Or fax to: (605) 322-4540
If you have any questions, please contact Network Services, Monday-Friday, 8 a.m. - 5 p.m. CT at (605) 322-4545 or toll-free at 1 (888) 322-2115.
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Provider Request for Reconsideration Form
Provider disputes are a way for providers to contest a claims processing determination regarding contracted fee schedule rates. At this time, there are no State regulations defining this process, however, Avera Health Plans will strive to respond to inquiries in a timely manner.
Our Provider Request for Reconsideration Form (fill-able PDF form) is required to be submitted with all disputes. We also are providing our Provider Reconsideration Guidelines to help expedite the provider dispute process. This form will ensure all pertinent information is included with the initial request so there is not a delay with the review process.
If you have any questions pertaining to this process, please call Network Services, Monday-Friday, 8 a.m. – 5 p.m. CT at (605) 322-4545 or toll-free at 1 (888) 322-2115.
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