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Schedule AIHCP Durable Medical Equipment Provider Enrollment and Profile Maintenance Packetin.gov/medicaid/providersProvider Information1 .T ype of request:This packet is used for multiple purposes; select the purpose that applies:New enrollment – You are enrolling for the first time.Change of ownership – The ownership of your business has changed.New service location – You are already enrolled and want to enroll an additional service location.Revalidate enrollment – You received a letter indicating you must revalidate your enrollment.Profile update – You are already enrolled and you need to change your Provider Profile information.Provider InformationThe National Provider Identifier (NPI) must be the proper NPI type based on the organizational structure of theenrolling individual or entity per the federal W-9 form. A DME provider that is conducting business as an individual or as asole proprietor (including single-member limited liability companies [LLCs] electing to do business as individuals), even ifthe individual operates under a doing business as (DBA) designation, must use a Type 1 NPI. A DME provider that isconducting business as an organization or distinct subpart of an organization (including single-member LLCs electing to dobusiness as corporations) must use a Type 2 NPI.A taxonomy code identifies a healthcare provider type and specialty; it is not a universal physician identification number (UPIN),Medicare provider number, or an IHCP provider number. The full provider taxonomy code set can be found at wpc-edi.com underthe Reference tab. The taxonomies requested in field 4 are the taxonomies associated with the NPI in field 2.2 . N ational Provider Identifier (NPI)3 . ZI P 4 (Nine digits required)5b. If yes, what is your IHCP Provider ID?5 a. A re you currently enrolled as an IHCP provider?YesNo6 a . Were you previously enrolled as an IHCP provider?Yes4. Taxonomy code6 b. I f yes, what was your previous IHCP Provider ID?No7. A re you s ubmitting this packet as the res ult of a c hange of owners hip? (I f Y es, c omplete the Change8 . Requested enrollment effective dateof Owners hip Addendum and provide a c opy of the purc has e or s ales agreement as an attachment tothe pac ket.)YesNoContact Information The contact name and email relate to the person who can answer questions about the information provided in this packet.Providers will be enrolled to receive email notifications when new information is published to in.gov/medicaid/providers.Provide the email address where these notifications should be sent.Email addresses will be used for IHCP business only and will not be sold to or shared for other purposes.9 . Contact name10. Telephone11. Contact email address12. Email address for provider publicationsIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72634 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Service Location Name and Address The service location address must be a physical location. A post office box is not a valid service location address.The service location is the site where members obtain services and is either owned or rented by the provider; it is usuallywhere supporting documentation related to claims is maintained.Providers that provide services at a “place-of-service site,” such as at a hospital or nursing facility, should enter theirhome/business office as their service location address.If you are operating under a doing business as (DBA) designation different from your legal name, submit copies ofregistration documentation from the Secretary of State or your county recorder’s office showing the DBA ( 405 IAC 1-19.1b)has been registered. This document must be attached to the packet.If you are using this packet to change your business name, you must include a revised W-9 form as an attachment to thepacket. You must also submit registration documentation from the Secretary of State or your county recorder’s office as anattachment, except when the business name is your nonregistered personal name.For a personal name change, submit documentation showing proof of the name change. A provider’s updated license orappropriate certification may be presented as proof of a name change. If a provider license does not show the new name, anofficial document showing the legal name change is required.If your legal name and business name changes are the same, one set of attached documents will support both changes.13. Service location (DBA) name14. Indiana county (Indiana providers)15. Telephone16. Service location street address19. ZIP 4 (Nine digits required)17. City18. State20. Is claim documentation kept at this location?21. Are services provided in Indiana?YesNoYesNoDME Provider Out-of-State Questionnaire The IHC P has designated certain areas outside Indiana to be treated as “in-state” for the purposes of provider enrollmentand prior authorization. For a list of applicable counties and ZIP Codes, see Out-of-State Areas Designated as In-State forIHCP Providers at in.gov/medicaid/providers. Out-of-state DME providers not located in an area designated as in-state may still claim in-state enrollment if they cananswer yes to all the questions below. Supporting documentation is required.2 2 . D M E providers located outside I ndiana (and not in an area des ignated as in- state by the I HCP) mus t c omplete the following ques tions to bec ons idered for in- s tate enrollment s tatus:YesNoDo you maintain an Indiana business office, staffed during regular business hours,with telephone service?YesNoDo you provide service, maintenance, and replacements for Indiana members whoseequipment has malfunctioned?YesNoDo you qualify with the Indiana Secretary of State as a foreign corporation?YesNoDo you anticipate at least 70% of your Indiana business be rendered by mail order oronline purchases?IHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72635 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Legal Name and Home Office Address If you are conducting business as an individual or sole proprietor (even if you have a registered DBA), you mustenroll with the IHCP using your personal name as your legal name. You may use your Social Security number(SSN) or federal employer identification number (EIN) as the taxpayer identification number (tax ID) associatedwith the enrollment.If you are an organization conducting business as an entity such as a corporation or partnership, you must enrollwith the IHCP using your business name as the legal name. You must use the business’ federal EIN as the tax IDassociated with the enrollment.The legal name is considered to be the entity maintaining ownership of the named business. The legal name must be thecurrent name on tax, corporation, and other legal documents.The legal name and home office address must match exactly the information currently registered with the Secretary of State,if registered. This does not apply to informal associations such as sole proprietorships and general partnerships that are notregistered.The legal name, as well as the home office address and tax ID, must match exactly the information reported onthe W-9 attached to your IHCP enrollment.If you are using this packet to change your legal name or home office address, you must include a revised W-9 form as anattachment to the packet. You must also submit registration documentation from the Secretary of State or your countyrecorder’s office as an attachment, except when the legal name is a nonregistered personal name.For a personal name change, submit documentation showing proof of the name change. A provider’s updated license orappropriate certification may be presented as proof of a name change. If a provider license does not show the new n ame,an official document showing the legal name change is required. If the legal name changes on the W-9, a new W-9 must besubmitted.If your legal name and business name changes are the same, one set of attached documents will support both changes.2 3 . Legal name2 4 . Business name (DBA )2 5 . H ome office s treet address2 6 . City2 9 . Telephone2 7 . State3 0 . Current tax ID2 8 . ZIP 4 (Nine digits required)3 1 . Former tax I D (required only for reporting a tax I D change)Mailing Name and AddressThe mailing address is the location where the IHCP sends general correspondence. A post office box is acceptable for a mailingaddress.3 2 . Addressee3 3 . Telephone3 4 . Mailing street address3 5 . City3 6 . State3 7 . ZIP 4 (Nine digits required)Pay-To Name and Address The pay-to address is the location where the IHCP sends checks and general claims payment information. If this is a billingagent’s address, please provide the name, address, and telephone number of the billing agent. A post office box is acceptablefor this address.The pay-to name is the name that will appear as the payee on all checks.If the provider is using a billing agent, proof of authorization for the billing agent must be included as anattachment to the packet.38. Pay-to name39. Billing agent name (if applicable)40. Pay-to telephone41. Pay-to street address42. CityIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-726343. State6 of 3444. ZIP 4 (Nine digits required)IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Provider Specialty Information See the IHCP Provider Enrollment Type and Specialty Matrix at in.gov/medicaid/providers to determine the appropriatespecialty codes and supporting documentation requirements for enrollment.The DME provider type is 25.Only one primary specialty is permitted per packet.A taxonomy code identifies a healthcare provider type and specialty; it is not a UPIN, Medicare provider number, or an IHCPprovider number. The full provider taxonomy code set can be found at wpc-edi.com under the Reference tab. You may enterup to 15 taxonomies; enter only those that apply to this service location.45. Provider type (two-digit code)46. Primary specialty (three-digit code)47. Additional specialties, if applicable (three-digit codes)2548. Taxonomy codes associated with specialties and used for billingCertification and Licensing InformationIf the provider is applying for a home medical equipment (HME) specialty, a copy of the Home Medical Equipment License fromthe Indiana State Board of Pharmacy must be included as an attachment to the packet. Out-of-state providers must include acopy of any required license from the appropriate licensing board in their state.49. HME license number, if applicable50. Effective date51. Expiration date52. Issuing stateIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72637 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Schedule Bin.gov/medicaid/providersIHCP Durable Medical Equipment Provider Enrollment and Profile Maintenance PacketOrganizational Structure If your business is chain-affiliated, the information about the company or organization must be included in the disclosureinformation in Schedule C .If your business is operated by a management company or leased (in whole or in part) by another organization, informationabout the management company or organization must be included in the disclosure information in Schedule C .See the IRS website for instructions about reporting disregarded entity status.1 . P rovider entity legally organized and structured as (c heck only one) (this must match the information provided on the attached W-9)Individual/sole proprietor/single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company (LLC); select tax classification:C CorporationS CorporationPartnershipResetOther (please explain; see instructions on Federal W-9 form):2. Regis tered with Sec retary of State (E ntities doing bus iness in I ndiana, exc ept fo r informal as sociations s uch as s ole proprietorships or generalpartners hips, mus t be regis tered with the Sec retary of State. G o to in.gov/s os to find out how to c omplete the registration proc ess.)YesNo3 . D ate business startedYes6. Chain affiliatedYes5. Incorporation date (if answered yes in 4)4. Entity incorporatedNo7 . Operated by management company or leased (whole or part) by another organizationNoYesNoManaged Care Program ProviderAfter you are enrolled as an IHCP provider, if you are interested in enrolling as a provider with the IHCP’s managed careprograms, you must apply directly with one or more of the managed care entities (MCEs). Please see the Enrolling as aManaged Care Program Provider page at in.gov/medicaid/providers for information about the programs and the MC Es withwhich the State contracts for each.Medicare Participation If you are a Medicare provider, you must provide your Medicare identification numbers.Submit a copy of the Medicare number assignment letter or Explanation of Medicare Benefits associated with the Medicarenumbers provided. The documentation helps the IHCP validate the numbers processed in CoreMMIS.9. Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) number8. Medicare number10. Address of service location to which the Medicare number is assignedMedicaid Participation for Out-of-State ProvidersIf you are a provider located outside Indiana and participate in your home state’s Medicaid program, include proof ofparticipation as an attachment to this packet.11. Are you currently enrolled in your home state’s Medicaid program?YesNoPatient Population Information12. Percentage of patient population with the following payment sources:12a. M edicaid12b. Self-pay12c. Medicare12d. Other insurance(12 a, b, c, and d must add up to 100%)IHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72638 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Schedule CIHCP Provider Schedule C – Disclosure Information in.gov/medicaid/providersOverviewPlease complete all four sections of this form. Nonprofit providers must provide information for the business entity that ownstheir taxpayer identification number (tax ID).Disclosure Information: When completing this schedule to make changes to the list of disclosed individuals, make sure toinclude the names of all individuals that meet the disclosure requirements, even if the individuals had been previously discl osed.When an update is processed, any previously disclosed individuals that are not shown on the update form will be removed. Inother words, the previous list of disclosed individuals will be replaced with the updated list of disclosed individuals.Disclosure of Social Security Numbers: Schedule C is used to collect information required by state and federal regulations.Social Security numbers disclosed on this form are used to determine whether persons and entities named in an enrollmentpacket are federally excluded parties. Refusal to provide a Social Security number will result in rejection of this enrollmen tpacket.Consent To Release Social Security Numbers: Submission of information on this schedule indicates that consent has beengiven to the Indiana Family and Social Services Administration (FSSA) and its contractors to use the information, including t heSocial Security number, for the sole purpose of verifying eligibility to participate in the Medicaid program through the Office ofthe Inspector General, the Centers for Medicare & Medicaid Services, relevant licensing bodies, and other appropriate state a ndfederal agencies. It is further understood that the FSSA and its contractors may use a Social Security number so the office maydetermine eligibility for continued participation in the Medicaid program.IHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72639 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

C.1 Disclosure Information Individuals and/or Corporations with anOwnership or Control Interest in the ApplicantSection C.1.(A) Individuals with an Ownership or Control InterestPlease list all individuals with an ownership or control interest in the applicant. Include each person’s name, address, theindividual’s date of birth (DOB), and Social Security number (SSN). Also indicate the title (e.g., chief executive officer, owner,board member) and if an owner, the percent of ownership. Attach additional pages as needed.* Please refer to 42 CFR 455.101 for the definition of “persons with an ownership or control interest” to ensure that allindividuals are included. This should also include officers, directors, or partners as defined in sections 455.101(e) and (f).1a. Name of individual2a. Address3a. Title4a. % of ownership(if applicable)5a. Social Security number6a. Date of birth4b. % of ownership(if applicable)5b. Social Security number6b. Date of birth4c. % of ownership(if applicable)5c. Social Security number6c. Date of birth4d. % of ownership(if applicable)5d. Social Security number6d. Date of birth4e. % of ownership(if applicable)5e. Social Security number6e. Date of birth4f. % of ownership(if applicable)5f. Social Security number6f. Date of birth1b. Name of individual2b. Address3b. Title1c. Name of individual2c. Address3c. Title1d. Name of individual2d. A ddress3d. Title1e. Name of individual2e. Address3e. Title1f. Name of individual2f. Address3f. TitleIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-726310 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Section C.1.(B) Corporations with an Ownership or Control InterestIf a corporation, please list all corporations with an ownership or control interest in the applicant. Include the taxpayeridentification number (tax ID), the percent of ownership in the applicant, the primary business address, every business location,and P.O. Box address(es). Attach additional pages if needed.1a. Name of corporation2a. % of ownership3a. Primary business address4a. Tax ID5a. Every business location6a. P.O . Box address(es)1 b. N ame of c orporation2 b. % of owners hip3 b. P rimary bus iness address5 b. E very bus iness location4 b. T ax I D6 b. P .O . Box addres s(es)1 c . N ame of c orporation2 c . % of owners hip3 c . P rimary bus iness address5 c . E very bus iness locationIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72634 c . T ax I D6 c . P .O . Box address(es)11 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

Section C.1.(B) Corporations with an Ownership or Control Interest (continued)If a corporation, please list all corporations with an ownership or control interest in the applicant. Include the taxpayeridentification number (tax ID), the percent of ownership in the applicant, the primary business address, every business location,and P.O. Box address(es). Attach additional pages if needed.1 d. N ame of c orporation2 d. % of owners hip3 d. P rimary bus iness address4 d. T ax I D5 d. E very bus iness location6 d. P .O . B ox addres s(es)1 e. N ame of c orporation2 e. % of owners hip3 e. P rimary bus iness address4 e. T ax I D5 e. E very bus iness location6 e. P .O . Box addres s(es)1 f. N ame of c orporation2 f. % of owners hip3 f. P rimary bus iness address4 f. T ax I D5 f. E very bus iness locationIHCP Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-72636 f. P .O . Box address(es)12 of 34IHCP DME Provider Enrollmentand Profile Maintenance PacketVersion 8.0, July 1, 2019

C.2 Disclosure Information Subcontractors(Attach additional copies of this page if you need space for additional names.)Subcontractors – Please list all subcontractors in which the applicant has a 5% or more ownership or control interest. Includeany subcontr

IHCP DME Provider Enrollment and Profile Maintenance Packet Version 8.0, July 1, 2019 Before You Beg. in! You are encouraged to use the . . Medicare provider number, or an IHCP provider number. The full provider taxonomy code set can be found at wpc-edi.com under the Reference tab. The taxonomies requested in field 4 are the taxonomies .