The information that identifies and describes a specific Indiana Health Coverage Programs (IHCP) provider is called a provider profile. When information about your business changes, you are required to submit a profile update to the IHCP within 10 business days. Profile updates must be submitted electronically using the IHCP Provider Healthcare Portal (IHCP Portal) or by mail, using the appropriate paper forms.
Notes: The following options do not apply to ordering, prescribing or referring (OPR) providers. If you are updating an OPR enrollment, see Ordering, Prescribing or Referring Providers on this website.
A change of ownership (CHOW) is treated as a new enrollment rather than an update. Skip to the Change of Ownership section for more information.
Making Updates Using the IHCP Portal
The IHCP Provider Healthcare Portal is an internet-based solution that offers enhanced reliability, speed, ease of use and security to providers and other partners doing business with the IHCP. Providers can use the IHCP Portal to view and make updates to their provider profile. Delegates with the proper authorization can also access the portal to view and update profile information.
Making Updates Using Paper Forms
All provider profile updates may be made using paper forms. You may use stand-alone provider profile maintenance forms designed for certain updates or resubmit a full IHCP provider packet, detailing the updated information.
The following table provides links to stand-alone forms that may be used to update your provider profile. When you are making updates for which no stand-alone form exists, you must submit your updates using the appropriate IHCP provider packet. You may also choose to use the full IHCP provider packet if you are making numerous changes at the same time, to avoid having to submit multiple stand-alone forms.
Instructions:
- Download and complete the appropriate IHCP provider packet or stand-alone form:
- To submit updates using the IHCP provider packet, go to Complete an IHCP Provider Enrollment Application and select your provider type to locate the appropriate packet. Download the packet and then follow the instructions to complete the update.
- To submit updates using a stand-alone form, follow, select the appropriate form from the table below. Download the form and follow the instructions to complete the update. If other changes are needed, select and complete another form.
- Save a copy of all update forms and other documentation for your records.
- Mail the update forms and other required documentation to the following address:
IHCP Provider Enrollment
PO Box 50443
Indianapolis, IN 46250-0418
Stand-Alone Provider Profile Maintenance Forms | |
Form Name | Description |
When a group provider revalidates using paper forms, the group does not need to revalidate all rendering providers linked to the group. However, the group's revalidation packet must include an updated, signed IHCP Rendering Provider Agreement for each rendering provider actively linked to the group at the time of revalidation. | |
When a group provider revalidates using the IHCP Portal, the group does not need to revalidate all rendering providers linked to the group. However, the group's revalidation must include an updated, signed IHCP Rendering Provider Agreement and Attestation Form for each rendering provider actively linked to the group at the time of revalidation. | |
| IHCP Rendering Provider Tax ID / Date of Birth Maintenance Form | Practitioners who enroll with the IHCP as rendering providers must include their Social Security number (SSN) and their date of birth in their IHCP provider profile. Rendering practitioners who enrolled before this requirement went into effect, or who used a group provider's taxpayer identification number (TIN) for their IHCP enrollment, must update their profile with this information by submitting this paper form. Rendering providers cannot establish accounts on the IHCP Portal for online transactions without their SSN and date of birth on file. |
Use this form to submit changes to Clinical Laboratory Improvement Amendment (CLIA) Certificate information. This applies only to facilities with laboratories. | |
IHCP Provider Delegated Administrator Addendum / Maintenance Form | Use this form to grant, change or revoke authority for a specific individual to sign and submit certain documents on behalf of the provider. The form contains a list of the documents for which authority may be delegated. |
IHCP Provider Electronic Funds Transfer Addendum / Maintenance Form | Use this form to change direct deposit information. This form does not apply to rendering providers, because billing is performed by the group or clinic. |
Use this form to submit new or revised Medicare participation information to the IHCP for crossover claims. | |
Use this form to update the name and address information that is part of your provider profile. Four address types are maintained for each provider service location enrolled in the IHCP. See Provider Addresses Used by the Indiana Health Coverage Programs for more information. | |
| IHCP Provider Ownership and Managing Individual Maintenance Form | Use this form to report ownership changes (business and individuals) and changes of managing individuals in instances such as a change in board members, officers or directors; a partner buyout; or the death of an owner. This form includes a section that mirrors Schedule C – Disclosure Information in the provider packet for billing and group providers. (Note: If the ownership change is the result of the business entity undergoing a financial transaction such as a sale or merger, do not complete this form; instead, follow the instructions for Change of Ownership.) |
IHCP Provider Enrollment Recertification of Licenses and Certifications Form | Certain providers are required to recertify their enrollment credentials to continue to be enrolled with the IHCP. Providers receive written notification when it is time to recertify. Use this form when submitting recertification documents. |
Use this form to voluntarily disenroll from the IHCP. | |
Use this form to make changes to your current specialty. This form does not apply to provider types for which there is only one specialty; if there is only one specialty from which to choose, providers cannot change specialties. | |
IHCP Provider Taxpayer Identification Number Maintenance Form | Use this form to make changes to a business taxpayer identification number (TIN) for one or more service locations. |
Use this form to make changes to the disclosed individuals associated with a rendering Medicaid Rehabilitation Option (MRO) Clubhouse provider organization. This form applies to clubhouse providers rendering services through an IHCP-enrolled MRO provider. | |
The "Psych Under 21 rule" requires psychiatric residential treatment facilities (PRTFs) to provide attestations of compliance each year by July 21 (or by the next business day, if July 21 falls on a weekend or holiday). This rule applies only to provider type 03 – Extended Care Facility, specialty 034 – Psychiatric Residential Treatment Facility (PRTF). Use this form when submitting your annual attestation. | |
Use this link to go to the Internal Revenue Service (IRS) website and download the federal W‑9 form. Submit the W‑9 with your provider packet or update form, as required, or separately in response to a specific request – if, for example, you omitted the form in your initial submission. | |
Processing Your Update
For updates submitted by mail, please allow at least 15 business days for processing before checking the status of your update. Submitting updates via the IHCP Portal reduces the time needed for processing.
After the Provider Enrollment Unit processes your update, you will be notified 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 updating your profile via the IHCP Portal and your submission is rejected for missing or incomplete information, you must start over and submit a new update request that includes all the required information.
- If you are updating your profile 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 of the packet or stand-alone form.
- If the update request is complete, it will be processed and you will receive a notification.
Change of Ownership
A change of ownership (CHOW) is treated as a new enrollment rather than an update. To report a CHOW, the provider must submit a new application, either online through the IHCP Portal (selecting Change of Ownership as the provider request type) or by mail using the appropriate IHCP provider packet completed in its entirety, including the Change of Ownership Addendum. (To access the appropriate IHCP provider packet, go to Complete an IHCP Provider Enrollment Application and select your provider type.)
The following must be submitted along with the enrollment application:
- Appropriate licensure or other supporting documentation
- A copy of a purchase agreement, bill of sale or other documentation to verify the CHOW