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Update Your Provider Profile

• IHCP Provider Enrollment Transactions
• Affordable Care Act (ACA) Requirements
• Complete an IHCP Provider Packet
• Ordering, Prescribing or Referring Providers
• Update Your Provider Profile
• Recertify Provider Enrollment Licenses and Other Certifications
• Qualifying for Increased Physician Reimbursement for Primary Care Services
• Disenroll from the IHCP
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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.

Notes:

1. The options below do not apply to OPR providers. If you are updating an OPR enrollment, see the Participating as an OPR Provider page.
2. 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 Services page.

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 addenda.
• Submit appropriate licensure and/or other supporting documentation.
• 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 information.
• Change electronic funds transfer (EFT) information.
• Change organizational structure information, such as board of directors.
• Add specialties to an existing profile.

All other updates require the use of paper forms, as noted below.

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 directions provided.
• 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 table below
  • 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:

1. Form Name	Description
   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 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 required.
   IHCP 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 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 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 Medicare Number Maintenance Form	Use this form to submit new or revised Medicare participation information to the IHCP for crossover claims purposes.
   IHCP 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.
   IHCP Provider Recertification of Licenses and Certifications Form	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.
   IHCP Provider Disenrollment Form	Use this form to voluntarily disenroll from the IHCP.
   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.
   IHCP Tax Identification Maintenance Form	Use this form to make changes to a business taxpayer identification number (TIN) for one or more service locations.
   IHCP 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 - Psychiatric.
   IHCP PRTF 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.
   ACA Physician Self-Attestation Form for Increased Reimbursement for Primary Care Services	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.

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. Place all update forms and required documentation in an envelope.
4. Mail the update forms and other required documentation to the following address:
   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 paperwork.
• If the update request is complete, it will be processed and you will receive notification.