Follow the steps below to register as an out-of-network practitioner with Anthem of Indiana:


  1. Create a document answering the following questions. We recommend using Microsoft Word or Apple Pages and exporting as a PDF when complete. Please note: The answers in bold have been prefilled for you. 

    • Purpose:  add provider as a non-participating/ Out of network provider

    • Effective date: 

    • Provider’s Full Name: 

    • Provider Specialty: 

    • Providers License Number: 

    • Individual Provider’s NPI: 

    • Practice Tax ID: 

    • Practice/ Group NPI: 

    • Provider’s Practice Address(es) 

    • Provider’s Billing/ Remittance Address 

    • Provider’s Correspondence/ Mailing address 

    • Provider’s Contact Name 

    • Provider’s Contact Phone Number 

    • Provider’s Contact Person’s Email Address    

    • Specify whether you submit claims using a facility UB-04 or a professional CMS 1500 form: CMS 1500

  2. Open the Provider Maintenance Form here: https://www.anthem.com/provider/provider-maintenance-form/

  3. Select “Change State” on the right

  4. Select your state. The page will update and you will see your state selection at the top of the screen. 

  5. Scroll down and select ‘Provider Maintenance Form’

  6. On the next screen, select if you need to update for an individual or organization and select next.

  7. Fill in the required information on the next screen, select ‘commercial’ for the network, and select next. 

  8. On the next screen select you would like to update NPI number and Network Participation. 

  9. Fill in the required information. On the Network Participation screen select ‘Delete’ and ‘Commercial’ 

  10. Attach the PDF file created in step 1 and upload. This is what will register as non-participating / out of network. 

  11. Once complete, submit the form. You will receive a confirmation screen as well as an email confirmation.