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 form.
- The options below do not apply to OPR providers. If you are
updating an OPR enrollment, see the Participating as an OPR
- Self-attesting as a qualified physician for the temporary rate
increase in Medicaid payments for qualifying primary care services,
as authorized under the Affordable Care Act (ACA), is
considered an update to the Provider Profile for existing
providers. For that reason, the attestation form is included on
this web page. Under certain circumstances newly enrolling
physicians may be able to submit the self-attestation as a part of
the initial enrollment packet. More details on how to qualify
can be found on the
Qualifying for Increased Physician Reimbursement for Primary Care
Change of Ownership
A change of ownership (CHOW) cannot be performed as an update; a
CHOW is treated like a new enrollment. When a change of ownership
occurs, providers must do the following:
- Submit a new IHCP Provider Packet, including all appropriate
- Submit appropriate licensure and/or other supporting
- Submit a copy of a purchase agreement, bill of sale, or other
documentation to verify the CHOW.
Go to the Complete an IHCP Provider
Packet page and select your provider type to start the Change
of Ownership process.
Making Updates using Web interChange
Web interChange is an
interactive web application that allows you to access the Indiana
Health Coverage Programs (IHCP) computer system through the
Internet. Web interChange is fast, secure, and free and does not
require special software. You can make the following updates to
your profile using Web interChange:
- Change Mail To, Pay To, and Service Location address
- Change electronic funds transfer (EFT) information.
- Change organizational structure information, such as board of
- Add specialties to an existing profile.
All other updates require the use of paper forms, as noted
Making Updates Using Paper Forms
All provider profile updates may be made using paper forms;
either using stand-alone forms specifically designed for certain
updates or through resubmission of an IHCP Provider Packet,
detailing the updated information.
- The table below 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
- There are certain instances when you must submit updates using
the IHCP Provider Packet.
- Making updates for which no stand-alone forms exist in the
- Making numerous changes at the same time
In these instances, go to the Complete an IHCP Provider
Packet page and select your provider type to locate the
appropriate packet. When using the IHCP Provider Packet to make
updates, follow the instructions provided in the packet.
Select an update form from the list below:
IHCP Claim Certification Statement for Signature on File Addendum/
||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 in which submission of 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
Certification Maintenance Form
||Use this form to submit changes to Clinical Laboratory
Improvement Amendment (CLIA) Certificate information. This applies
only to facilities with laboratories.
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.
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.
Medicare Number Maintenance Form
||Use this form to submit new or revised Medicare participation
information to the IHCP for crossover claims purposes.
Name Address Maintenance Form
||Use this form to update the name and/or address information
that is part of your provider profile. Four address types are
maintained for each provider service location enrolled in the
IHCP Provider Recertification of Licenses and Certifications
||Certain providers are required to recertify their enrollment
credentials to continue to be enrolled with the IHCP. Providers
will 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.
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, the
provider cannot change their specialty.
Identification Maintenance Form
||Use this form to make changes to a business taxpayer
identification number (TIN) for one or more service
Psychiatric Hospital Bed Addendum/ Maintenance Form
||Complete this form to determine if your facility qualifies for
reimbursement as a 16 bed or less psychiatric facility. This form
only applies to provider type 01 - Hospital, specialty 011 -
Attestation Addendum/ Maintenance Form
||The ''Psych Under 21 rule" requires PRTF facilities 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
applies only to provider type 03 - Extended Care Facility,
specialty 034 - Psychiatric Residential Treatment Facility (PRTF).
Use this form when submitting your annual attestation.
|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.
Self-Attestation Form for Increased Reimbursement for Primary Care
||Use this form to self-attest as a qualified physician for the
temporary rate increase authorized under ACA, for Medicaid payments
for qualifying primary care services rendered in calendar years
2013 and 2014.
- If other changes are needed, select
and complete another form.
- Save a copy of all update forms and
other documentation for your records.
- Place all update forms and required
documentation in an envelope.
- Mail the update forms and other required documentation to the
HP Provider Enrollment
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 HP
Provider Enrollment Unit processes your update, they will notify
you of the results.
- If the update request is incomplete or the required
documentation is not present, you will be contacted by the HP
Provider Enrollment Unit in an attempt to complete the transaction.
If, after contact, the update cannot be completed, the entire
submission will be returned to you with a letter stating the
problem. You will need to make corrections and resubmit the update
- If the update request is complete, it will be processed and you
will receive notification.