Update Your Provider Profile
The information that identifies and describes a specific
provider is called a Provider Profile. When information about your
business changes, you are required to submit a profile update to
the Indiana Health Coverage Programs (IHCP) within 10 business
days. Profile updates must be submitted electronically using Web
interChange or on the appropriate paper forms.
Note: The following options do not apply to
ordering, prescribing, and referring (OPR) providers. If you are
updating an OPR enrollment, see Participating as an
OPR Provider on this website.
Change of Ownership
A change of ownership (CHOW) cannot be performed as an update; a
CHOW is treated as a new enrollment. When a change of ownership
occurs, providers must submit the following:
- A new IHCP provider packet, including all appropriate
- Appropriate licensure or other supporting documentation
- A copy of a purchase agreement, bill of sale, or other
documentation to verify the CHOW.
Go to Complete an IHCP
Provider Packet and select your provider type to start the
change of ownership process.
Making Updates using Web interChange
interChange is an interactive web application that allows you
to access the IHCP computer system through the Internet. Web
interChange is fast, secure, and free, and does not require special
software. Providers that use Web interChange and have appropriate
administrative privileges can update their profile information via
Web interChange. To avoid delay when updating the provider profile,
use Web interChange, rather than sending a paper form. Using Web
interChange, you can:
- Change "mail-to" and "pay-to" addresses
- Change "service location" address, as long as yours is not a
moderate or high risk-level specialty, in which case a paper update
form must be submitted
- Add additional specialties to an existing profile, as long as
the specialty is not defined as moderate or high risk. Changes to
your primary specialty cannot be made on Web interChange.
- Enroll in electronic funds transfer (EFT) or change existing
- Enroll as a qualified provider for the Presumptive Eligibility
for Pregnant Women process. Only certain specialties can enroll as
qualified providers; for a complete list of provider types, see the
Presumptive Eligibility for Pregnant Women provider
reference module on this site.
- Enroll as a qualified provider for the Hospital Presumptive
Eligibility Qualified Provider process. For more information, see
Presumptive Eligibility provider reference module on this
- Enroll as a qualified provider for the Presumptive Eligibility
process. For more information, see the
Eligibility provider reference module on this site.
- Enroll in IHCP programs such as Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)/HealthWatch; Medical Review Team
(MRT); the 590 Program; and Pre-admission Screening Resident Review
- Register for the Electronic Health Records (EHR)
- Indicate that you are accepting new patients or patients with
special needs (dental providers)
All other updates require paper forms.
Making Updates Using Paper Forms
All provider profile updates may be made using paper forms. You
may use stand-alone forms designed for certain updates or resubmit
an IHCP provider packet, detailing the updated information.
- The following table provides links to stand-alone forms used to
update your Provider Profile. Select the appropriate form from the
list and download it to your computer for completion, following the
- When you are making updates for which no stand-alone forms
exist in the following table, you must submit your updates using
the IHCP provider packet.
- When you are making numerous changes at the same time, you may
submit updates using the IHCP provider packet, rather than using
individual stand-alone forms.
If you are submitting updates using the IHCP provider packet, go
to Complete an IHCP
Provider Packet and select your provider type to locate
the appropriate packet, then follow the instructions in the
Select an update form from the following list:
IHCP Claim Certification Statement for Signature on File
Addendum/ Maintenance Form
All UB billing providers that submit paper claims are required
to complete this form. Other providers that submit claims
electronically are not required to complete the form but
should do so to cover instances when submitting a
paper claim is necessary. Rendering providers are not required to
complete the form. After you complete this transaction, paper
claims will not need a signature to be adjudicated because the
signature will be "on file." An owner, authorized official, or
delegated administrator with the business must sign the form. An
original signature is required.
Provider CLIA Certification Maintenance Form
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
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
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.
Provider Medicare Number Maintenance Form
Use this form to submit new or revised Medicare participation
information to the IHCP for crossover claims.
Provider Name and Address Maintenance Form
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.
IHCP Provider Enrollment Recertification of Licenses and
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.
Provider Disenrollment Form
Use this form to voluntarily disenroll from the IHCP.
Provider Specialty Maintenance Form
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.
Provider Taxpayer Identification Number Maintenance
Use this form to make changes to a business Taxpayer
Identification Number (TIN) for one or more service locations.
IHCP MRO Clubhouse Provider Enrollment Addendum
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
IHCP Psychiatric Hospital Bed Addendum/ Maintenance
Complete this form to determine whether your facility qualifies
for reimbursement as a 16-bed or less psychiatric facility. This
form applies only to provider type 01 - Hospital, specialty 011 -
IHCP PRTF Attestation Letter/ Maintenance Form
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.
Link - IRS W-9
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.
- If other changes are needed, select and complete another
- Save a copy of all update forms and other documentation for
- Mail the update forms and other required documentation to
Hewlett Packard Enterprise (HPE) at the following address:
Provider Enrollment Unit
P.O. Box 7263
Indianapolis, IN 46207-7263
Processing Your Update
Please allow at least 20 business days for mailing and
processing before checking the status of your update. After the
Provider Enrollment Unit processes your update, you will be
notified of the results.
- If the packet needs correcting or is missing required
documentation, the Provider Enrollment Unit will contact you by
telephone, email, fax, 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 an
application is rejected for missing or incomplete information, the
entire packet will be returned to the provider with a letter
indicating what needs to be corrected or attached. Providers MUST
return the entire packet, as well as a copy of the provider letter,
when submitting the correction or missing information.
- If the update request is complete, it will be processed and you
will receive notification.