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 IHCP
Provider Healthcare Portal (Portal) or by mail, using 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
Ordering, Prescribing, or Referring Providers on this website. A change of ownership (CHOW) is treated as a new enrollment rather than an update. To report a CHOW, the provider must submit a new application, either online through the Portal
(selecting Change of Ownership as the provider request type) or by mail using the appropriate IHCP provider packet completed in its entirety, including the Change of Ownership Addendum. (To access the appropriate IHCP provider packet, go to Complete an IHCP Provider Enrollment Application and
select your provider type.) The following must be submitted along with the enrollment application: The IHCP
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. Providers can use the Portal to view and make updates to their provider profile. Delegates with the proper authorization can also access the Portal to view
and update profile information. All provider profile updates may be made using paper forms. You may use stand-alone forms designed for certain updates or resubmit a full IHCP provider packet, detailing the updated information. Instructions: IHCP Provider Enrollment Unit 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 Rendering Provider Agreement and Attestation Form When a group provider revalidates using the Portal, the group does not need to revalidate all rendering providers linked to the group. However, the group's revalidation must include an updated, signed IHCP Rendering Provider Agreement and Attestation Form for each rendering provider actively linked to the group at the time of revalidation. 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. Use this form to report ownership changes (business and individuals) and changes of managing individuals in instances such as a change in board members, officers, or directors; a partner buyout; or the death of an owner. This form includes a section that mirrors Schedule C – Disclosure Information in the provider packet for billing and group providers. (Note: If the ownership change is the result of the business entity undergoing a financial transaction such
as a sale or merger, do not complete this form; instead, follow the instructions for Change of Ownership.) 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. For updates submitted by mail, please allow at least 15 business days for processing before checking the status of your update. Submitting updates via the Portal reduces the time needed for processing. After the Provider Enrollment Unit processes your update, you will be notified of the results. How do I change my Medicaid plan in Nevada?Email Nevada Medicaid to ask for a plan change and include your name, Medicaid ID and the names and Medicaid IDs of any dependents in your home: [email protected]. Call your local Medicaid district office at 775-687-1900 (northern Nevada) or 702-668-4200 (southern Nevada) to ask about changing your plan.
How do I change my Medicaid plan in Virginia?Change Your Health Plan. For Medicaid Enrollment.. Web: www.coverva.org.. Tel: 1-833-5CALLVA.. TDD: 1-888-221-1590.. How do I change my Medicaid plan in Kentucky?To change your managed care organization, call toll free (855) 446-1245 or (800) 635-2570 from 8 a.m. to 6 p.m. Eastern time to speak with a Medicaid services representative or go online to the kynect website. All plan changes made during open enrollment will take effect on Jan. 1, 2023.
How do I change my Medicaid plan in Louisiana?Health plan and dental plan changes can be made by visiting the Healthy Louisiana website (myplan.healthy.la.gov); using the Healthy Louisiana mobile app; calling 1-855-229-6848; or completing the paper enrollment form that is mailed to members and following the directions on the form to return it.
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