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FIRST STEPS/INDIANA HEALTH COVERAGEPROGRAMS (IHCP)PROVID ERUPDATEA PPLICATIONGeneral InstructionsThis form is used to update provider enrollment records for a billing service location and groupmember. Please do not use this form to add new enrollments, add new service locations, or reportchanges of ownership. This form is used for the following updates: Changes to service location, mail to, pay to, and home office addresses for billing providers (renderingproviders do not have address information) Update licenses or certifications for billing providers or rendering providers (Recertifications) Change tax identification/Social Security number, if not related to a change of ownership Add a new Clinical Laboratory Improvement Amendment (CLIA) Certification Enroll in the 590 Program, MRT, and Health Watch Note: In order to participate with First Steps Program, itis a requirement for providers to enroll as Medicaid provider. However, there are several provider specialtiesthat are excluded from this requirement due to the fact that the specialty is NOT ineligible to participate inIHCP. Please refer to Provider Specialty Listing to identify specialties that are ineligible for participation withIHCP. Begin Electronic Funds Transfer (EFT) Reinstate a provider number (lapse in eligibility must be less than 12 months) Voluntarily terminate enrollment, including group members Can be used to enroll group members to an actively enrolled group provider Change rendering provider (group member) informationIf enrolling a new service location or undergoing a change of ownership, please obtain a ProviderEnrollment Application form available on the Internet at http://www.infirststeps.com or by request onefrom the Provider Enrollment line at 1-877-707-5750.Please complete all applicable sections for the provider number and service location requested. Eachsection includes specific instructions. Please read the instructions carefully. Many of the updatesrequire documentation be attached. Please include a copy of all necessary documents when submittingthis form.Mailing InstructionsFully complete the form and enclose copies of all required licenses, forms, and certifications, and sendthe entire packet to the following address:EDS – Provider EnrollmentP.O. Box 7263Indianapolis, IN 46207-7263When the update request has been reviewed, EDS Provider Enrollment will notify you in writing aboutthe status of your update. Please allow at least 30 business days for mailing and processing time beforechecking on the status of the update request.QuestionsDirect any questions about this form to Provider Enrollment at 1-877-707-5750 or visithttp://www.infirststeps.com.EDSP. O. Box 7263Indianapolis, IN 46207-7263Page 1 of 15July 2006Version 1.2

FIRST STEPS AND INDIANA HEALTH COVERAGE PROGRAMSPROVID ERUPDATEFORM1. Billing Provider Information:Submission Date:Provider Number:Location Alpha Suffix(es):Provider Name:Federal Tax Identification Number/Social Security Number:Update2. Service Location Name and AddressGenerally, the service location name and address is for the site where members go to obtain services from the perspectiveprovider. A service location maintains the supporting documentation related to the claim submitted for a service. The servicelocation name must be the Doing Business As (DBA) name registered with the Secretary of State, except for sole proprietorsor business owners who must register their Assumed Business Name with their county recorder. Anesthesiologists whoprovide services at multiple locations should enter their home office as their service location. The address must be a physicallocation. A post office box is not a valid service location address.Provider Name:Indiana County:DBA Name:Telephone:Street Address:City:State:Fax:ZIP 4:-E-mail:Is claim documentation kept at this location?YesNoIf this is not an Indiana address, are services provided in Indiana?YesNo3. Legal Name and Home Office AddressUpdatePlease complete the contact information for the home office of the legal entity maintaining ownership of the above servicelocation. The legal name must be the current name on tax, corporation, and other legal documents, and the name currentlyregistered with the Secretary of State, or filed with the county recorder as the Assumed Business Name. The address must bea physical location. A post office box is not a valid home office address.Legal Name:Telephone:Street Address:City:State:Fax:ZIP 4:-Email:EDSP. O. Box 7263Indianapolis, IN 46207-7263Page 2 of 15July 2006Version 1.2

First Steps/IHCPProvider Update Form4. Mailing Name and AddressUpdatePlease complete the contact information for bulletins, provider manual updates, and general correspondence. A post officebox is an acceptable mailing address.Name:Telephone:Street Address:City:State:Fax:ZIP 4:-E-mail:5. Pay-to Name and AddressUpdatePlease complete the information for the addressing of checks, remittance advices, and general claims payment information.The name listed below as the Payee Name will appear as the payee on all checks. A post office box is acceptable for thisaddress. Complete Schedule H to authorize or delegate payments is made to any entity other than the provider.Name:Telephone:Street Address:City:State:Fax:ZIP 4:-E-mail:Billing Agent?YesNoUpdate6. Federal Tax InformationTaxpayer Identification Number/Social Security Number:Effective Date:A copy of a completed IRS Form W-9 must be submitted with this update form. Failure to attach this form will resultin EDS returning this form for incomplete information.7. Provider Licensing/Recertification InformationUpdatePlease refer to the Provider Type and Specialty Matrix to determine the appropriate code for your specialty. Primary andsecondary specialties must be from the same provider type, and only codes listed on the Type and Specialty Matrix will beaccepted.Primary Specialty:Secondary Specialty:License Number:Licensing Board:License Effective Date:License Expiration Date:A copy of the license from the appropriate licensing board must be submitted with this update form. Failure to attach a copyof the license may result in EDS returning this form for incomplete information.8. Matrix Provider InformationUpdateLicense or Certification Description:Degree:Degree Description:NOTE: *The licensing state must match the service location state. A copy of the license from the appropriatelicensing board must be submitted with this application. Failure to attach a copy of the license will result in EDSreturning the entire application as incomplete.EDSP. O. Box 7263Indianapolis, IN 46207-7263Page 3 of 15July 2006Version 1.2

First Steps/IHCPProvider Update FormUpdate9. CLIA CertificationPlease complete this section with the information from your Clinical Laboratory Improvement Amendment (CLIA)Certificate. CLIA certificates are issued to specific service locations, unless you are eligible for the multiple site exceptionthrough the Department of Health and Human Services.CLIA Number:Certification Type:Effective Date:Expiration Date:Update10. Medicare ParticipationPlease complete this session for updates to the billing provider’s Medicare number. If you need to update a renderingprovider’s (group member’s) Medicare number you must complete and submit Schedule G with this update formMedicare Number:DMERC Number:Unique Provider Identification Number (UPIN):A copy of the assignment letter must be attached to this form. Failure to attach a copy of the letter may result inMedicare crossover claims not crossing over to the IHCP.Update11. 590 ParticipationThe 590 Program is a State medical assistance program providing reimbursement for medically necessary covered medicalservices provided off site to individuals who reside in State institutions. Check the box labeled yes if you wish toparticipate in this program. The following provider types cannot be 590 providers: transportation, hospice, home health,DME, and LTC facilities.YesNoEffective Date:Update12. Do you wish to participate in the Medical Review Program?The Medical Review Program provides determination of an applicant’s eligibility for Medicaid under the disabilitycategory. The provider completes a medical assessment of an applicant and submits the required forms to the Office ofFamily Resources. The MRT issues a favorable or unfavorable eligibility decisions based on medical evidence thatsupports whether the applicant has a significant impairment. Once the documentation has been filed, the provider maysubmit claims to EDS for payment of certain examination and reports. Services should not be performed unless theapplicant has presented the pre-Medicaid eligibility form.YesNoEffective Date:Update13. Provider Number ReinstatementProvider Number:Service Location:If you want to reinstate a provider number that has been terminated due to provider request or provider inactivity, pleasecheck yes below. Provider numbers may be reinstated when the provider number has been closed for one year or lesssubject to enrollment requirements. If a provider number has been closed one year or longer, a new application must besubmitted to reinstate the provider number.Do you wish to reinstate this provider number?YesNoPlease submit Schedules B and C if organizational structure or disclosure information has changed.EDSP. O. Box 7263Indianapolis, IN 46207-7263Page 4 of 15July 2006Version 1.2

First Steps/IHCPProvider Update Form14. Voluntary Termination (for billing providers only).You must use Schedule G for rendering provider voluntary terminations.Provider Number:UpdateService Location(s):If you are voluntarily terminating your participation in one of the Indiana Health Coverage Programs, please complete thedate of voluntary termination and the termination reasons in the field below. Please note that only the location specifiedabove will be terminated. If no locations are specified, then the entire provider number including all service locations willbe terminated.TerminationReasonRetiredDeceasedTermed by provider: closed service locations,no longer participating in program, or for anyother reason not specifiedOut ofBusinessChangedOwnershipBankruptcy (please submit copy of bankruptcyfiling or judgment)You must complete address fields 3 (Mailing) and 4 (Pay To) of this form providing the current forwardinginformation.If the termination request is for a PMP, you must contact the appropriate MCO to terminate participation due tocontractual requirements for member continuity of care.15. EFT (Schedule I)Provider Number:UpdateService Location(s):You must attach a completed Schedule – EFT Form to the update request form before a change will be made toyour EFT information.16. Provider Organizational Structure (Schedule B) and DisclosureInformation (Schedule C)Provider Number:UpdateService Location(s):You must attach a new, completed Schedule B and C for any changes to your organizational structure anddisclosure information. Do not use this form for ownership changes (CHOW); it is to be used for changes to theorganizational structure or disclosure information submitted on your original enrollment application. Providersare required to report changes to disclosure information within 45 days of effective date of change.17. Change of Ownership (CHOW)Provider Number:Long-term Care ProviderNotificationService Location(s):Non Long-Term Care ProviderExpected Date of Ownership Transfer:Actual Date of Ownership Transfer:This form may be used to report the date of an expected transfer of ownership. All billing provider types, the oldowner may complete the Provider Update form. The new owner must complete a new Provider EnrollmentApplication form indicating in box 1, that the enrollment is for a CHOW and complete all information in ScheduleD – Change of Ownership.EDSP. O. Box 7263Indianapolis, IN 46207-7263Page 5 of 15July 2006Version 1.2