Keeping your practice data current is vital to facilitating effective member referrals, claims processing and correspondence. Updating your information online helps ensure correct, accurate data in Magellan's systems and available to members searching for a provider.
Provider Data Change Form
Sign in securely on this website to access the online Provider Data Change Form. Most changes you make will upload in real-time to Magellan's systems, ensuring we always have the most up-to-date information for your practice. You can securely update:
- Billing, mailing, service and home addresses
- Phone and fax numbers
- Email addresses
- Hours of operation
- Taxpayer Identification Number
- License and specialty information
- Roster members
- And much more.
To review your practice information and make changes, sign in and click Display/Edit Practice Information from the left menu.
Medicaid Disclosure Form
Medicaid providers must complete and submit the Medicaid Disclosure Form (PDF). Magellan is contractually obligated to collect the information on this form and will provide it to the health plan and/or State Medicaid agency. We highly encourage you to securely sign in to this website to complete the online version of the Medicaid Disclosure Form, rather than mailing a hard copy.
If you change your billing Taxpayer Identification Number (TIN), you must complete and submit an online Form W-9 listing the legal name of the payee and the type of TIN – Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer Identification Number (ITIN).
Sign in securely on this website to access the online W-9. Once signed in:
- Click Display/Edit Practice Information on the left-hand menu under MyPractice.
- On the Provider Data Change Form tab, select the appropriate MIS/TIN combination and click Go.
- Click W-9 Form.
- To submit a new form, click Submit Online.
1099 Contact Information
For inquiries regarding your Form 1099, please contact Nancy Innes at 1-800-450-7281, ext. 75001.