Update Your Provider Profile

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 Provider Healthcare Portal 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

If you are reporting a change of ownership (CHOW), it is treated as a new enrollment rather than an update. When providers report a change of ownership via paper form, providers must submit the following:

  • A new IHCP provider packet, including all appropriate addenda
  • 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.

Note: Changes of ownership for long-term care facilities will continue to be completed only via paper forms until further notice. Watch for more information in IHCP bulletins and banner pages and on this website.

Making Updates using the Provider Healthcare Portal

The Indiana Health Coverage Programs (IHCP) Provider Healthcare Portal (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.

In the Portal, you can perform the following profile update transactions:

  • Enroll as a qualified provider for the presumptive eligibility process. For more information, see the Presumptive 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 (PASRR)
  • Register for the Electronic Health Records (EHR) Incentive Program
  • 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 and complete it, following the directions provided.
  • When you are making updates for which no stand-alone forms exist in the following table, you must submit your updates using the appropriate 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 packet.

Select an update form from the following list:

Form Name

Description

IHCP Rendering Provider Agreement

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.

IHCP Claim Certification Statement for Signature on File Addendum/ Maintenance Form

All billing providers that submit institutional 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.

IHCP 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 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.

IHCP Provider Medicare Number Maintenance Form

Use this form to submit new or revised Medicare participation information to the IHCP for crossover claims.

IHCP 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. See Provider Addresses Used by the Indiana Health Coverage Programs for more information.

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.

IHCP Provider Disenrollment Form

Use this form to voluntarily disenroll from the IHCP.

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.

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.

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 provider.

IHCP Psychiatric Hospital Bed Addendum/ Maintenance Form

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 - Psychiatric.

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 Form

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.

  1. If other changes are needed, select and complete another form.
  2. Save a copy of all update forms and other documentation for your records.
  3. Mail the update forms and other required documentation to the IHCP at the following address:
    Provider Enrollment Unit
    P.O. Box 7263
    Indianapolis, IN 46207-7263

Processing Your Update

Please allow at least 15 business days for 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 submission 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 your update is submitted via the Portal, and your submission is rejected for missing or incomplete information, the update must be corrected via the Portal. If your update is submitted via paper, the entire submission will be returned to you. Providers MUST return the entire submission to make corrections or provide the missing information.
  • If the update request is complete, it will be processed and you will receive notification.