How to Fill Out and Submit the CareSource Hierarchy Change Request Form

The CareSource Hierarchy Change Request Form is the PDF you use to add a provider to a billing group, remove one, or correct a provider’s demographic details in CareSource’s system. Download it from CareSource’s document library, complete it along with a current W-9, and send both to providermaintenance@caresource.com or fax them to (937) 396-3076.1CareSource. CareSource Provider/Group Hierarchy Change Request Form

When to Use This Form

Three situations call for it, and you check the matching box at the top of page one:

  • A practitioner is joining a group that already participates in CareSource’s network. The form links that provider’s individual NPI and credentials to the group’s Tax Identification Number so claims process under the correct billing entity.
  • A practitioner is leaving the group, whether through retirement, a move to another organization, or ending CareSource participation altogether.
  • A provider’s details need correcting: practice location, specialty, NPI, phone or fax, product additions or deletions, patient capacity, or age restrictions.

The common case is a provider moving between practices. If a physician leaves a private practice for a hospital-employed group, claims need to route to the hospital’s TIN rather than the old practice’s. Until the hierarchy updates, payments can land at the wrong entity.

What to Have Ready Before You Start

Most form rejections trace back to missing or stale information. Pull the following together first:

  • Group identifiers: the IRS-registered name, any DBA name, group TIN, group NPI, and the group’s Medicare and Medicaid numbers.
  • Individual provider details for everyone on the form: name and degree, street address, city, state, county, zip, phone, fax, individual NPI, CAQH number, Medicaid and Medicare numbers, specialty, and whether the provider is a PCP. For PCPs, you’ll also need patient capacity and any age or gender restrictions.
  • Signatory information: the name, title, and email of the person legally authorized to sign on behalf of the group.
  • A current W-9 for the group, submitted alongside the form. It confirms the TIN and legal entity that will receive payments.1CareSource. CareSource Provider/Group Hierarchy Change Request Form
  • An updated CAQH profile for each affected provider. CareSource’s instructions specifically note that all CAQH applications should be updated and accurate before submission.2CareSource. CareSource Provider Group Change Request Form

Have the provider log into CAQH ProView, update practice location, group affiliation, and anything else that has changed, then re-attest. CareSource pulls from CAQH during verification, and a profile that isn’t current flags for manual review and stalls the whole update.

Completing Each Section

Request Type and Products

Check the box for the type of change: add, delete, or demographic update. Just below, select which CareSource products the change applies to. Options vary by state and include Medicaid, MyCare, Marketplace (Just4Me), and Medicare Advantage across Ohio, Kentucky, Indiana, and West Virginia.1CareSource. CareSource Provider/Group Hierarchy Change Request Form Check every product the provider participates in. Missing one here means the hierarchy stays unchanged for that line of business even if you intended a blanket update.

Group Information and Addresses

Enter the IRS-registered name, DBA, TIN, NPI, and Medicare and Medicaid numbers for the group. The form then asks for three addresses: remit-to (where payments go), mailing (where correspondence goes), and contractual updates. If the mailing or contractual address matches the remit address, indicate that rather than re-entering everything. You’ll also indicate whether the group qualifies as a Federally Qualified Health Center, Rural Health Clinic, Qualified Family Planning Provider, or Community Mental Health Center.

Office Contact and Signatory

The office contact is who CareSource will call or email with questions about the form. The signatory is whoever has legal authority to bind the group, listed with name, title, and email.1CareSource. CareSource Provider/Group Hierarchy Change Request Form The two can be the same person, though in larger organizations the contact usually sits in credentialing operations while the signatory is a medical director or practice administrator.

Provider Information Table

Page two is a table with one row per provider: name and degree, full practice address, phone, fax, individual NPI, CAQH number, Medicaid and Medicare numbers, specialty, PCP status, patient capacity (if PCP), and age restrictions. Add rows as needed when the change covers multiple providers.1CareSource. CareSource Provider/Group Hierarchy Change Request Form

For Indiana Medicaid, primary medical providers are limited to no more than two service locations and must identify their capacity at each one. The notes section on the last page is where you add anything that doesn’t fit the table fields: effective dates, special circumstances, or details about a demographic update.

How to Submit It

There are three delivery options:

  • Email the completed form and W-9 to providermaintenance@caresource.com. This address handles hierarchy changes across all CareSource products and states.
  • Fax to (937) 396-3076, which is the same number for Medicaid, MyCare, Medicare Advantage, D-SNP, and Marketplace provider information changes.3CareSource. Communicating with CareSource
  • Route it through your dedicated CareSource Provider Relations representative, if your group has one.2CareSource. CareSource Provider Group Change Request Form

Whichever route you take, confirm the W-9 is attached and the CAQH profiles are current before it goes out. If you fax, verify the transmission went through. A failed fax with no follow-up looks exactly like never submitting at all.

Processing Time and Follow-Up

CareSource’s processing window runs from 10 to 60 days depending on the type of change.4CareSource. Working with CareSource Health Partner Orientation Ohio Market A simple phone number correction tends to move faster than adding a new provider, which involves credentialing verification. Payments continue flowing under the old hierarchy until the update takes effect.

If something is wrong or missing, CareSource contacts the office contact listed on the form for corrections. Common kickback reasons include a TIN that doesn’t match the W-9, an outdated or incomplete CAQH profile, a missing product selection, or a provider NPI CareSource cannot verify. Fixing and resubmitting restarts the clock, so accuracy on the first pass pays off.

For questions during processing, CareSource’s provider services line handles general enrollment inquiries at 1-800-488-0134 for Medicaid, MyCare, and Marketplace products, and 1-844-679-7865 for Medicare Advantage.3CareSource. Communicating with CareSource

Keeping the Hierarchy Current

CareSource expects notice of demographic changes before the effective date, not after.4CareSource. Working with CareSource Health Partner Orientation Ohio Market Submitting ahead of a provider’s start or departure date prevents a window where claims route to the wrong TIN or reject outright.

When the group’s TIN itself changes through a merger, acquisition, or restructuring, the stakes rise. Every provider linked to the old TIN needs re-association with the new one, and the W-9 has to reflect the new entity. Moving everyone in a single batch rather than piecemeal keeps the providers on the same timeline, and coordinating with your Provider Relations representative before filing avoids surprises partway through.