Become a Contracted Provider | Indiana HealthCare

Provider TIN *

Group NPI *

Name *

Legal Name *

Contact Name *

Contact Phone *

Contact Email *

Please attach a copy of your W-9 *

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Tax ID Number *

Group NPI Number *

Specialty

Contract Type *

Medical Behavioral Health Medical & Behavioral Health

Contract Products*

All Products Hoosier Healthwise Healthy Indiana Plan (HIP) Hoosier Care Connect Ambetter from MHS Allwell from MHS

I have verified that I am currently active with IHCP *

Yes No

Please enroll in IHCP here

Contact Name *

Contact Title *

Contact Phone *

Contact Email *

Legal Name (W9) *

Legal Practice Name *

CAQH Number *

DEA Number (if applicable)

By checking this box, you certify that you have reviewed your CAQH profile within the last 120 days and attest that the information is accurate and up to date.

Be sure:

Your document expiration dates are no more than 30 days from the date of request to avoid documents expiring during the credentialing process.
You are not missing any required CAQH documents.
You do not have any errors in your CAQH profile.

The following information is required in your CAQH profile for credentialing:
Medical Liceanse	DEA/CDS Certificate (if applicable)
Medicaid Number (if requesting Medicaid participation)	Medicare Number (if requesting Medicare participation)
Board Certification	Specialties
Liability Insurance	Practice Location Information
Professional Training	Admitting Privileges
Hospital Affiliations	Credentialing Contact

Required for Provider (Practitioner/Group) Credentialing/Enrollment

(* denotes additional required BH Forms, if applicable)

IHCP MCE Practitioner Enrollment Form (PDF)

Please attach completed IHCP Practitioner Enrollment Form *

If there are 10 or more practitioners to be enrolled with a group contract request, please utilize the Practitioner Enrollment Spreadsheet.

Please attach completed Practitioner Enrollment Spreadsheet, if applicable.

*BH Provider Specialty Profile (BH Only) (PDF)

Please attach completed BH Provider Specialty Profile

Ambetter & Allwell Provider Enrollment Form (PDF)

Please attach completed Ambetter & Allwell Provider Enrollment Form *

Provider Location Listing Spreadsheet

Please attach completed Provider Location Listing Spreadsheet *

Collaborative Agreement (required for NP/PA/CNS)

Please attach completed Collaborative Agreement

Provider Credentialing Disability Form (Medical Groups Only) (PDF)

Please attach completed Provider Credentialing Disability Form *

HSPP Attestation (BH Only) (PDF)

Please attach completed HSPP Attestation

W-9

Please attach a copy of your W-9 *

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Tax ID Number *

Individual NPI Number *

Group NPI Number *

Specialty

Contract Type *

Medical Behavioral Health Medical & Behavioral Health

Contract Products*

All Products Hoosier Healthwise Healthy Indiana Plan (HIP) Hoosier Care Connect Ambetter from MHS Allwell from MHS

I have verified that I am currently active with IHCP *

Yes No

Please enroll in IHCP here

Contact Name *

Contact Title *

Contact Phone *

Contact Email *

Legal Name (W9) *

Legal Practice Name *

State License Number (if applicable)

DEA Number (if applicable)

Required for Ancillary Providers

(* denotes additional required BH Forms, if applicable)

Provider Location Listing (only Location Listing tab required for Ancillary requests)

Please attach completed Provider Location Listing form

IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form (PDF)

Please attach your IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form. Required for Medical & BH *

Accreditation Certificate

(required for ancillary provider only)

Please attach a copy of your Accreditation Certificate *

BH Facility and Ancillary Demographic Info* (PDF)

Please attach your completed BH Facility and Ancillary Credentialing Application

Copy of Medicaid Certification Letter

Please attach a copy of your Indiana Medicaid Certification Letter *

Copy of Medicare Certification Letter

Please attach a copy of your Indiana Medicare Certification Letter *

Liability Coverage

Please attach a copy of your Liability Coverage *

CLIA Certificate

Please attach a copy of your CLIA Certificate *

W-9

Please attach a copy of your W-9 *

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Tax ID Number *

Individual NPI Number *

Group NPI Number *

Specialty

Contract Type *

Medical Behavioral Health Medical & Behavioral Health

Contract_Products*

All Products Hoosier Healthwise Healthy Indiana Plan (HIP) Hoosier Care Connect Ambetter from MHS Allwell from MHS

I have verified that I am currently active with IHCP *

Yes No

Please enroll in IHCP here

Contact Name *

Contact Title *

Contact Phone *

Contact Email *

Legal Name (W9) *

Legal Practice Name *

IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form (PDF)

Please attach your IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form. Required for Medical & BH *

W-9

Please attach a copy of your W-9 *

Group/Provider Name *

Tax ID Number *

Provider NPI *

Contact Name *

Contact Email *

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