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 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.

Making Updates using Web interChange

Web 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 EFT information
  • 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 the Hospital Presumptive Eligibility provider reference module on this site.
  • 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 for completion, 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 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 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.

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.

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 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.