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OverviewIHCP Group and Clinic Provider Application and Maintenance Formwww.indianamedicaid.comDear Prospective Provider:Thank you for your interest in the Indiana Health Coverage Programs (IHCP). This IHCP provider application iscustomized to meet the needs of groups and clinics. It is important to complete each field in the application to preventthe form from being returned for correction. Ensure that the appropriate person(s) have signed your forms.If you are currently enrolled and you need to make multiple changes to your current provider profile, this form can beused for that purpose. If you have a specific change request, refer to the provider maintenance forms. For example,use the IHCP Address Maintenance Form to change an address or the Electronic Funds Transfer (EFT) form to make achange to your direct deposit account with the IHCP.Group and Clinic Provider Types:The following providers are eligible to enroll as a group or clinic. Groups and Clinics must have renderingproviders (practitioners) linked to their business service locations.Provider Type and Description08 Clinic17 Therapist27 Dentist09 Advanced Practice Nurse18 Optometrist29 Radiologist11 Mental Health20 Audiologist31 Physician14 Podiatrist21 Case Manager15 ChiropractorRefer to the Provider Type and Specialty Matrix available on the IHCP Web site ices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf todetermine the document requirements for your provider type and specialty. Based on your provider type, thematrix informs you about whether you qualify to be a billing provider. Enter your type and specialtyinformation in Schedule A – Provider Information.You may submit as many as 15 taxonomies per National Provider Identifier (NPI). If you need more spacethan what is provided, you may attach a separate sheet listing additional taxonomies and their associated NPI.Business Structure:All groups and clinic providers receive a group provider classification. A group or clinic provider is abusiness entity that submits claims for services provided by rendering practitioners that work in their servicelocations. Because clinics must link rendering providers to their service locations, clinics are given a groupclassification. Groups and clinics are responsible for submitting claims to the IHCP by any submission means,including paper, electronic, or the Web interChange for reimbursement. The group provider may be anorganization or corporation.Schedules, Provider Agreement, and Addenda:Complete the following sections. The IHCP Group and Clinic Provider Application and Maintenance Packet isdivided into the following sections: Schedule A – Provider Information - This section collects information related to the prospectiveprovider including name, address information, provider type, and provider specialty. Complete all fields. Schedule B – Organization Structure - This section collects information about the provider’s business.In addition, Providers may also indicate participation in additional programs. The following programs arelisted in Schedule B: Page 1 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, OverviewVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
HealthWatch is a preventative health care program offered to Medicaid-eligible members younger than21 years of age. Physicians or nurse practitioners who are enrolled as Medicaid providers are qualified toperform HealthWatch screenings. Reimbursement for HealthWatch services is higher than equivalentservices billed using standard CPT codes. HealthWatch screenings must be completed in accordance withrecommendations set forth in the HealthWatch Provider Manual Periodicity Schedule. Check the boxlabeled yes to receive the HealthWatch Provider Manual. The 590 Program is a State medical assistance program providing reimbursement for medicallynecessary covered medical services provided off site to individuals who reside in State institutions. Thefollowing provider types cannot be 590 providers: transportation, hospice, home health, DME, and longterm care facilities. There are no out-of-state 590 providers. The Medical Review Program provides determination of an applicant’s eligibility for Medicaid underthe disability category. The provider completes a medical assessment of an applicant and submits therequired forms to the Office of Family Resources. The MRT issues a favorable or unfavorable eligibilitydecision based on medical evidence that supports whether the applicant has a significant impairment.Once the documentation has been filed, the provider may submit claims to EDS for payment of certainexamination and reports. Services should not be performed unless the applicant has presented the preMedicaid eligibility form. To participate solely in the Medical Review Program, the provider should checkthe Medical Review Program ONLY. Providers that choose not to participate in the IHCP Programs andhave been requested to submit medical records, should check MRT Medical Records. Schedules C.1-C.4 Consent to Release Social Security Numbers. The top of Schedule C.1 contains a section that describesthe purpose for release of social security numbers and to whom a Social Security number may be released.Schedules C.1, C.2, and C.3 contain signature fields to acknowledge consent for each individual named in theSchedules. Disclosure of Social Security Numbers is voluntary. Refusal to provide a social securitynumber will result in rejection of this application. Disclosure Information - Schedule C.1. This section collects information required by federal regulationthat details information about those entities or individuals with five percent direct or indirect ownership inthe prospective provider’s business and the degree of relationship for each individual. Ownership and Control, Subcontractor Relationships - Schedule C.2. - List the Name, Title, FEIN,and Business Address of any person or entity that has an ownership or controlling interest in anysubcontractor in which the provider entity has direct or indirect ownership of five percent or more. Managing Individuals - Schedule C.3. List all managing individuals as defined on Schedule C.3. Relationships and Background Information - Schedule C.4. Documents family relationshipsinvolved in the provider entity and provider background information. The disclosure of social securitynumbers is used only for the purpose of determining whether persons and entities named in the applicationare federally excluded parties. Refusal to provide a social security number will result in rejection of thisapplication. Profile Maintenance Signature Page. This page is completed and signed when an additional servicelocation is enrolled, or the form is used to make several changes to the group or clinic’s provider’s servicelocation profile. Provider Agreement – The IHCP Provider Agreement must be completed and signed. The ProviderAgreement is the first document in this packet following the IHCP Group and Clinic Provider Application andMaintenance Form. Federal W-9 Form – The W-9 form must be completed and signed. Attached Addenda: Additional forms are available from the IHCP Web site at www.indianamedicaid.com. The Electronic Funds Transfer Addendum is included in this packet. Submission of this form allowsproviders to obtain payment by direct deposit. Submit the Claim Certification Statement for Signature on File Addendum that is included in this packet.Processing this document allows adjudication of paper claims without a hand written signature on eachform. (Providers that submit claims on the UB form must complete the above named addendum.) The Change of Ownership Addendum is included in this packet. The purchasing provider is responsiblefor submitting all change of ownership information in addition to a new enrollment application packet.Additionally, a copy of the purchase or sales agreement must be included. Page 2 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, OverviewVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
Mailing Instructions:Retain a copy of the completed application and maintenance packet for your records. Enclose the signedProvider Agreement and copies of all required documentation as listed on the following checklist, and mail theentire packet to the following address:EDS – Provider EnrollmentP.O. Box 7263Indianapolis, IN 46207-7263Application Processing:After the Provider Enrollment Unit receives, reviews, and processes a provider application and maintenanceform, the provider receives notification. If the form is incomplete or the required supporting documentation isnot present, the entire packet is returned. An instructional letter stating the reason(s) the request was notcompleted is included with the packet. If the IHCP denies an application, the provider receives notificationexplaining the denial reason. Please allow at least 30 business days for mailing and processing beforechecking the status of the submitted provider forms.Refer to the IHCP Web site at www.indianamedicaid.com for additional information or contact the ProviderEnrollment Helpline at 1-877-707-5750 for assistance in completing an IHCP Provider Application andMaintenance Form.Application and Maintenance Checklist:The following checklist is designed to assist providers and the IHCP in completing and verifying that information isincluded in this packet.ForProviderUse OnlyFor IHCPUse OnlyDid you remember to .Complete all IHCP Group and Clinic Provider Application and Maintenance Form Schedules (A, B,and C).Complete and sign the IHCP Provider Agreement for an initial enrollment.Complete and submit the necessary signatures for profile maintenance. A signed provideragreement is not required for profile maintenance.Complete and sign the current Federal W-9 form for tax identification purposes.Include copies of license(s) or permits for your provider specialty or specialties .Include a copy of your Medicare Assignment Letter, if applicable.(Out-of-state groups and clinics must submit proof of participation in Medicare or their State’sMedicaid Program.)Complete the Change of Ownership Addendum, if applicable.Complete all of the Rendering Provider forms and signatures.Include all other elected addenda.Recertification:Individuals who practice outside of Indiana must recertify to extend their eligibility. This process occurs at the time oflicensure renewal. To recertify, submit the IHCP Provider Recertification Form available at www.indianamedicaid.com. Page 3 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, OverviewVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
Schedule AIHCP Group and Clinic Provider Application and Maintenance Formwww.indianamedicaid.comProvider Information1. Request Type:New EnrollmentAdditional Service LocationUpdate2. IHCP Provider Number and Alpha Suffix: (If currently enrolled)3. National Provider Identifier4. ZIP 4: (Nine digits required)5. Taxonomies:6. Document Submission Date:7. Requested Enrollment Effective Date:-8. Change of Ownership?YesNo(If Yes, complete the enclosed Change of Ownership Addendum)Billing Provider Office Location Name and AddressThe billing provider office location name and address is for the site where members obtain services and is either owned orrented by the billing provider. This location maintains supporting documentation related to the claim. The billing provider officelocation name must be the Doing Business As (DBA) name registered with the Secretary of State, except for informalassociations (Sole Proprietorship and General Partnerships). Providers, who provide services at a “place of service site,” such asa hospital or nursing facility, should enter their home/business office as their billing provider office location address and not theplace of service address. The address must be a physical location. A post office box is not a valid billing provideroffice location address.9. DBA Name:10. Indiana County:11. Telephone:12. Street Address:15. ZIP 4: (Nine digits required)13. City:14. State:16. Is claim documentation kept at this location?17. Are services provided in Indiana?YesNoYesNoLegal Name and Home Office AddressThe home office is considered to be the legal entity maintaining ownership of the above billing provider office location. The legalname must be the current name on tax, corporation, and other legal documents, and currently registered with the Secretary ofState, or filed with the State as the Assumed Business Name. The legal name and business name, as well as the address,must match what is listed on the W-9.18. Legal Name:19. Street Address:21. State:20. City:22. ZIP 4: (Nine digits required)23. Telephone:24. Tax ID Number: Page 4 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, Schedule AVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
Mailing Name and AddressThe mailing address is the location where the IHCP sends provider bulletins, newsletters, manuals, and general correspondence.A post office box is acceptable for a mailing address.26. Telephone:25. Name:27. Street Address:28. City:30. ZIP 4: (Nine digits required)29. State:Pay To Name and AddressThe pay to address is the location where the IHCP sends checks, remittance advices, and general claims payment information. Ifthis is a billing agent’s address, please provide the name, address, and phone number of the billing agent. The name listedbelow as the Payee Name will appear as the payee on all checks. A post office box is acceptable for this address. Billing agentsmust furnish proof of authorization to be the billing agent for provider.31. Payee Name:32. Billing Agent Name:33. Telephone:34. Street Address:35. City:37. ZIP 4: (Nine digits required)36. State:Contact NameThe contact person is the person who answers questions about the information provided in this form.39. Telephone:38. Contact Name:40. Contact E-mail:41. Would you like a link to the Web interChange application sent to your E-mail address?YesNo42. Are you willing to receive IHCP bulletins and newsletters via E-mail or the Web?YesNoProvider Specialty InformationRefer to the Provider Type and Specialty Matrix on the IHCP Web site to determine the appropriate provider type, specialtycodes, and enrollment requirements for this application. Only one provider type code is permitted per application. Submit aseparate application for each additional provider type.43. Provider Type (two digit code):44. Primary Specialty (three digit code):45. Additional Specialties:46. Taxonomies (Enter only those taxonomies that apply to this service location):CLIA CertificationDocument your Clinical Laboratory Improvement Amendment (CLIA) Certificate information in this section. CLIA numbers areassigned to one specific service location unless CMS exemption status is met.47. CLIA Number:49. Effective Date:48. Certification Type:50. Expiration Date:Note: A copy of the certificate must be attached to the application. Failure to attach a copy of the certificate willresult in denied claims for laboratory services. Page 5 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, Schedule AVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
Schedule BIHCP Group and Clinic Provider Application and Maintenance Formwww.indianamedicaid.comOrganizational Structure1. Provider Entity Legally Organized and Structured As (Check only one):For Profit CorporationNot For Profit CorporationPartnershipGovernment OwnedLimited Liability CompanyOther, please specify2. Registered with Secretary of State*:Yes* If yes, submit a copy of the state registration papers (405 IAC 1-19.1b). If no, and yourbusiness name is different from your name, please submit a copy of the Assumed BusinessName form on file with the State.No3. Date Business Started:4b. If answered Yes in 4a, Incorporation Date:4a. Entity Incorporated:Yes5. Chain Affiliated **YesSole ProprietorshipLimited Liability PartnershipNo** If yes, the information about the company or organization must be included in thedisclosure information.No6. Operated by Management Company or Leased (Whole or Part) by Another Organization*** :YesNo***If yes, the information about the companyor organization must be included in thedisclosure information.Previous IHCP Enrollment Information7a. Are you currently, or have you ever been enrolled as an IHCP provider?Yes7b. IHCP Provider Number(s):No7c. National Provider Identifier:7d. ZIP 4: (Nine digits required)7e. Taxonomies:Other IHCP Program ParticipationProviders may elect to participate in additional programs. The application overview provides detailed information about each ofthe programs listed in this section.8. Participate in the HealthWatch Program:Yes9a. Participate in the 590 Program:NoYesNoYesNo10b. MRT Participation:10a. Participate in the Medical Review Program:Yes9b. Participate in the PASRR Program:NoMedical Record Copying onlyMedicare ParticipationPlease provide the appropriate Medicare identification numbers.Out-of-state providers must submit proof of participation in Medicare and their state’s Medicaid program. See the Type andSpecialty Matrix for specific document requirements.11. Medicare Number:12. Issuing State:13. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Number:14. Address for Location Where the Medicare Number is Assigned:Note: A copy of the Medicare number assignment letter (or a Medicare Remittance Notice with correct Medicarenumber) is recommended to ensure accuracy of Medicare number assignment.Patient Population Information15. Percentage of your patient population with the following payment sources:15a. Medicaid:15b. Self-Pay:15c. Medicare:15d. TPL:(15a, b, c, and d must add up to 100%) Page 6 of 39 IHCP Group and Clinic Provider Application and Maintenance Form, Schedule BVersion 2.0, April 2009EDS Provider Enrollment UnitP.O. Box 7263Indianapolis, IN 46207-7263
Schedule CIHCP Group and Clinic Provider Application and Maintenance Formwww.indianamedicaid.comC.1 – Disclosure Information – Ownership and Control, Provider EntityInstructions: Please complete all four sections of Schedule C – Ownership and Control, Provider Entity; Ownershipand Control, Subcontractor Relationships; Managing Individuals; and Relationships and Background Information.Non-profit providers must list the business entity that owns their tax identification number.Disclosure of Social Security Numbers: Disclosure of social security numbers is used for the purpose of determiningwhether persons and entities named in an application are federally excluded parties and to verify licensure. The IHCP ProviderApplication and Profile Maintenance Form's C Schedules are used to collect information required by State and federalregulations. The regulations detail information about those entities or individuals with five percent direct or indirect ownership inthe prospective provider’s business and the degree of relationship for each individual. Disclosure of Social Security Numbers isvoluntary. Refusal to provide a social security number will result in rejection of this application.*Consent To Release Social Security Numbers: All persons whose names are written in boxes marked 1a ofSchedules C1, C2, and C3 are asked to place their signature in box 1b. A signature in box 1b shall indicate that the signatoryagrees to the following statement regarding the disclosure of his or her social security number:My signature in box 1b in Schedule C1, C2, or C3 indicates that I give my express consent to the Office of MedicaidPolicy and Planning and its contractors to disclose my social security number for the sole purpose of verifying myeligibility to participate in the Medicaid p
IHCP Group and Clinic Provider Application and Maintenance Form, Overview EDS Provider Enrollment Unit Version 2.0, April 2009 P.O. Box 7263 Indianapolis, IN 46207-7263 Page 1 of 39 Dear Prospective Provider: Thank you for your interest in the Indiana Health Coverage Programs (IHCP). This IHCP provider application isFile Size: 2MB
