Skip to Main Content

search

Home
Find a Provider
Portal Login
Events
Careers
Contact Us

Contrast On Off

a a a

English
Spanish

For Members show For Members submenu
For Providers show For Providers submenu
Get Insured

MENU

SEARCH

search

English
Spanish

Home
Find a Provider
Portal Login
Events
Careers
Contact Us

Login
Find a Provider
For Members
For Providers
Get Medical Insurance in Indiana | MHS Indiana
About Us
Contact Us
Newsroom
- Press Releases
Privacy Policy
Terms & Conditions
Notice of Privacy Practices
Careers

For Providers
Login
Enrollment and Updates
Prior Authorization
Dental Providers
Pharmacy
Opioid Resources
Behavioral Health Providers
Provider Resources
QI Program
Provider News
Email Sign Up
Coronavirus Information

Existing Contracted Entity

Contract Type *

Medical - Diagnostic Radiology, Pathology, ER Physician, Anesthesiology (non-pain management), CRNA Medical - Other Behavioral Health

Error: This field is required.

Please do not use this form unless you are one of the following specialties: Diagnostic Radiology, Pathology, ER Physician, Anesthesiology (non-pain management), or CRNA.

If you are enrolling additional specialties, please select Medical (Other) above.

Tax Identification Number *

Error: This field is required.

Provider/Group NPI (if additional NPIs are needed please submit a new request) *

Error: This field is required.

Provider/Group Indiana Medicaid Number

Provider/Group Name *

Error: This field is required.

Provider/Group Specialty *

Error: This field is required.

Service/Location Name *

Error: This field is required.

Service/Location Address (only 1 per TIN/GNPI) *

Error: This field is required.

Service/Location Suite Number

Service/Location City *

Error: This field is required.

Service/Location State *

Error: This field is required.

Service/Location Zip *

Error: This field is required.

Service/Location Main Phone Number *

Error: This field is required.

Service/Location Main Fax Number

Error: This field is required.

Billing Name *

Error: This field is required.

Billing Address *

Error: This field is required.

Billing City *

Error: This field is required.

Billing State *

Error: This field is required.

Billing Zip *

Error: This field is required.

Billing Phone Number *

Error: This field is required.

Billing Fax Number

Error: This field is required.

Practitioner Name

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Practitioner Gender *

Male Female

Error: This field is required.

Practitioner NPI *

Error: This field is required.

Degree (select one) *

MD DO DPM NP Other

Error: This field is required.

If other, what degree?

Practitioner Taxonomy Code *

Error: This field is required.

Practitioner Email Address *

Error: This field is required.

Practitioner Specialty *

Error: This field is required.

Practitioner Indiana Medicaid Number

Error: This field is required.

Enrolling in Hoosier Healthwise *

Yes No

Error: This field is required.

Enrolling in Healthy Indiana Plan *

Yes No

Error: This field is required.

Enrolling in Hoosier Care Connect *

Yes No

Error: This field is required.

Enrolling in Ambetter MHS IN *

Yes No

Error: This field is required.

Enrolling in Allwell MHS IN *

Yes No

Error: This field is required.

Comments

Enrollment Requested By:

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone *

Error: This field is required.

Date *

Error: This field is required.

Error: Please complete the captcha

CAQH Number *

Error: This field is required.

Practitioner Name

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Practitioner NPI *

Error: This field is required.

Degree (select one) *

MD DO DPM NP Other

Error: This field is required.

If other, what degree?

Practitioner Email Address

Practitioner Taxonomy Code *

Error: This field is required.

Do you offer telehealth appointments? *

Yes No

Error: This field is required.

Enrolling in Hoosier Healthwise? *

Yes No

Error: This field is required.

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Error: This field is required.

Maximum Membership/Panel Size

Enrolling in Healthy Indiana Plan? *

Yes No

Error: This field is required.

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Error: This field is required.

Maximum Membership/Panel Size

Enrolling in Hoosier Care Connect? *

Yes No

Error: This field is required.

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Error: This field is required.

Maximum Membership Panel Size

Enrolling in Ambetter from MHS? *

Yes No

Error: This field is required.

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Error: This field is required.

Maximum Membership Panel Size

Enrolling in Allwell from MHS *

Yes No

Error: This field is required.

If yes, enrolling as: *

PMP with Panel Physician Specialist Nurse Practitioner Other

Error: This field is required.

Maximum Membership/Panel Size

Do you ONLY provide care in a facility setting?

Yes No

Error: This field is required.

(i.e. hospital-based, hospitalist, etc.)

Age Restrictions*

None 0-2 Years 0-12 Years 0-20 Years 3+ Years 13+ Years 0-17 Years 13-20 Years 17+ Years 21+ Years 65+ Years

Error: This field is required.

Group NPI

Error: This field is required.

Group Medicaid Number *

Error: This field is required.

Alpha Suffix

Error: This field is required.

TIN *

Error: This field is required.

Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

MCE Universal Enrollment Form (for HHW, HIP and/or HCC, or for all products)

Practitioner Enrollment Form (Ambetter/Allwell only)

If a midlevel practitioner, please attach a copy of your collaboration agreement.

Comments

Enrollment Requested By:

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone *

Error: This field is required.

Date *

Error: This field is required.

Error: Please complete the captcha

CAQH Number *

Error: This field is required.

Practitioner Name

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Practitioner NPI *

Error: This field is required.

Degree (select one) *

MD PhD HSPP LCSW Other

Error: This field is required.

If other, what degree?

Practitioner Email Address

Error: This field is required.

Primary Taxonomy Code *

Error: This field is required.

Do you offer telehealth appointments? *

Yes No

Error: This field is required.

Enrolling in Hoosier Healthwise? *

Yes No

Error: This field is required.

Enrolling in Healthy Indiana Plan? *

Yes No

Error: This field is required.

Enrolling in Hoosier Care Connect? *

Yes No

Error: This field is required.

Enrolling in Ambetter from MHS? *

Yes No

Error: This field is required.

Enrolling in Allwell from MHS? *

Yes No

Error: This field is required.

Do you ONLY provide care in a facility setting?

Yes No

Error: This field is required.

(i.e. hospital-based, hospitalist, etc.)

Age Restrictions*

None 0-2 Years 0-12 Years 0-20 Years 3+ Years 13+ Years 13-20 Years 17+ Years 21+ Years 65+ Years

Error: This field is required.

Group NPI *

Error: This field is required.

Group Medicaid Number *

Error: This field is required.

Alpha Suffix

Error: This field is required.

TIN *

Error: This field is required.

Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

MCE Universal Enrollment Form (for HHW, HIP and/or HCC, or for all products)

Practitioner Enrollment Form (Ambetter/Allwell only)

Additional Forms

Behavioral Health Specialty Profile (PDF)

Please attach a copy of your Behavioral Health Specialty Profile. *

Error: File upload is required.

If a midlevel practitioner, please attach a copy of your collaboration agreement.

Comments

Enrollment Requested By:

First Name *

Error: This field is required.

Last Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone *

Error: This field is required.

Date *

Error: This field is required.

Error: Please complete the captcha

Home
Events
Newsroom
About Us
Contact Us
Member Handbook
Careers

Language Assistance
Statement of Non-Discrimination
Notice of Privacy Practices
Terms & Conditions
Site Map
Report Fraud
Privacy Policy

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

1-877-647-4848

© Copyright 2020 Centene Corporation