11 – Behavioral Health Provider

The Indiana Health Coverage Programs (IHCP) enrolls the following specialties under provider type 11 – Behavioral Health Provider:

• 110 – Outpatient Mental Health Clinic
• 111 – Community Mental Health Center (CMHC)
• 114 – Health Service Provider in Psychology (HSPP)
• 115 – Adult Mental Health and Habilitation (AMHH) Service Provider
• 611 – Children's Mental Health Wraparound (CMHW) Service Provider
• 612 – Behavioral and Primary Healthcare Coordination (BPHC) Service Provider
• 613 – Medicaid Rehabilitation Option (MRO) Clubhouse
• 615 – Applied Behavior Analysis (ABA) Therapist (Masters/Doctoral or HSPP)
• 616 – Licensed Psychologist
• 617 – Licensed Independent Practice School Psychologist
• 618 – Licensed Clinical Social Worker (LCSW)
• 619 – Licensed Marriage and Family Therapist (LMFT)
• 620 – Licensed Mental Health Counselor (LMHC)
• 621 – Licensed Clinical Addiction Counselor (LCAC)
• 622 – Mobile Crisis Unit
• 623 – Certified Community Behavioral Health Clinic (CCBHC)
• 624 – Applied Behavior Analysis (ABA) Therapist (Bachelors)
• 625 – Applied Behavior Analysis (ABA) Therapist (Registered Behavior Technician [RBT])
• 835 – Opioid Treatment Program (OTP)
• 836 – Substance Use Disorder (SUD) Residential Addiction Treatment Facility

Initiating Your Enrollment Transaction

The following steps outline the basic enrollment process for this provider type. More detailed information is available in the Provider Enrollment provider reference module.

1. Refer to the IHCP Provider Enrollment Type and Specialty Matrix for a list of the documentation required for IHCP enrollment or revalidation under each applicable provider specialty.


2. See the IHCP Provider Enrollment Risk Category and Application Fee Matrix to determine your risk level and whether you are required to pay an application fee. The enrollment or revalidation screening process is determined by the risk level that applies to your provider type. At its discretion, the IHCP may assign a provider a higher risk level that supersedes the risk level assigned by the Centers for Medicare & Medicaid Services (CMS) and noted on the matrix.
   • Generally, provider specialty 615 is considered "high" risk at enrollment and "moderate" risk at revalidation. Provider specialties 624 and 625 are considered "high" risk at enrollment. High- and moderate-risk categories are subject to additional screening measures, including pre-enrollment site visits. High-risk provider types are also subject to fingerprint background check requirements. Individuals with at least 5% ownership or controlling interest in the enrolling entity, as well as rendering providers, must be fingerprinted and must include fingerprinting confirmation number with the submission. See the Provider Enrollment Risk Levels and Screening page for instructions for fingerprinting.
   • Generally, the following provider specialties are considered "moderate" risk and are subject to additional screening measures, including a pre-enrollment site visit:
     • Provider specialties 111, 115, 612, 622 and 623 (for enrollment and revalidation)
     • Provider specialty 836 (for enrollment)
   • Generally, all other behavioral health provider specialty enrollments or revalidations are considered "limited" risk and are not subject to additional screening measures.
   • Providers with specialty 111, 611 (group only), 615 (group and billing only) or 836 are required to pay an application fee during enrollment, revalidation or change of ownership for each service location. Submit confirmation of your electronic payment of the fee to the IHCP or document in your enrollment submission that you have paid the fee to Medicare or another state Medicaid program. All other specialties are not required to pay the fee.
3. Providers are encouraged to use the IHCP Provider Healthcare Portal (IHCP Portal) to enroll, add a service location, report a change of ownership, revalidate or update provider profile information. Providers will find the online process much quicker and easier than using paper forms. Online help guides users through the process from start to finish and provides immediate confirmation of enrollment submissions.
   
   If you choose to enroll or update by mail, instead, you may do so using the appropriate IHCP provider packet, as described below (detailed instructions are included in the packets):
   • Select the appropriate IHCP provider packet as follows:
     • For specialty 836, use the IHCP Hospital and Facility Provider Enrollment and Profile Maintenance Packet.
     • For all other specialties under type 11 (except specialties 115 and 612, which can only be added as secondary specialties onto an existing enrollment for specialty 111), select one of the following packets based on your provider classification:
       • To enroll as a billing provider (allowed for specialties 114, 611, 615–621 and 835), use the IHCP Billing Provider Enrollment and Profile Maintenance Packet.
       • To enroll as a group or clinic (allowed for specialties 110, 111, 114, 611, 615–623 and 835), use the IHCP Group and Clinic Provider Enrollment and Profile Maintenance Packet.
       • To enroll as a rendering provider (allowed for specialties 114, 611, 613, 615–621, 624 and 625), use the IHCP Rendering Provider Enrollment and Profile Maintenance Packet.
   • To enroll, add a service location, report a change of ownership or revalidate a current IHCP enrollment, you must complete the entire packet.
   • To update an existing provider profile, submit the appropriate provider profile maintenance form, or complete the relevant sections and submit the IHCP provider packet, following the instructions provided. See the Update Your Provider Profile page on this website.
   • The IHCP provider packet is an interactive PDF file, allowing you to type information into the fields electronically, save the completed file to your computer and print the file for mailing.
   • Before mailing, make a copy of the completed IHCP provider packet and required documentation for your records.
   • Mail the packet and other required documentation to the following address:
     IHCP Provider Enrollment
     PO Box 50443
     Indianapolis, IN 46250-0418
4. After you are enrolled as an IHCP provider, if you are interested in enrolling as a provider with the IHCP's managed care program, you must apply directly to one or more of the managed care entities (MCEs). Please see the Enrolling as a Managed Care Program Provider page for information about the programs and the MCEs with which the state of Indiana contracts for each. Links to the MCE enrollment forms follow – use the form appropriate for your provider type:
   • IHCP MCE Practitioner Enrollment Form
   • IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form

Processing Your Enrollment Transaction

Please allow at least 15 business days for processing before checking the status of your submission. After your transaction is processed, the IHCP Provider Enrollment Unit will notify you of the results.

• If the submission needs correcting or is missing required documentation, the Provider Enrollment Unit will contact you by telephone, email or mail. This contact is intended to communicate what needs to be corrected, completed and submitted before the IHCP can process your enrollment transaction.
  • If you are enrolling via the IHCP Portal and your submission is rejected for missing or incomplete information, the submission must be corrected in the portal. Providers will have 21 business days to make corrections, or the application will expire.
  • If you are enrolling via paper, a letter will be sent indicating what needs to be corrected or attached. Providers must attach a copy of this letter as a cover sheet when they submit the missing or corrected pages.


• If the submission is complete, the Provider Enrollment Unit will process your transaction and conduct the appropriate screening associated with your assigned risk level.


• If the IHCP approves your enrollment or revalidation, you will receive a verification letter from the Provider Enrollment Unit.


• If the IHCP denies your enrollment or revalidation, you will receive a notification letter explaining the reason for denial. If you believe your enrollment or revalidation was denied in error, you may appeal. See the Provider Enrollment provider reference module for information about the appeal process.

Note: Letters from the IHCP Provider Enrollment Unit are sent in envelopes that display the Indiana Family and Social Services (FSSA) logo and the words "IMPORTANT MEDICAID INFORMATION INSIDE."