Non-Contracted Provider Set-Up

The preferred and quickest method for enrolling a non-contracted provider or practitioner is via a claim submission.

Please submit your claim and we will complete enrollment based on the NPI, TIN and program of the submitted claim, which will be processed in approximately 21 days.

If you would like to proceed with submitting a non-contracted enrollment request, you may do so by clicking the button below. Please note enrollments processed via request may take up to 60 days to process. If sending a claim, please do not also submit a request.

Complete Non-Contracted Enrollment

W9 Form * Please attach a completed W9. Please submit enrollments through your Provider Relations staff member if you bill with a SSN as your TIN.

Is this an update or a new submission? *

Yes, we are already set-up with MHS No, we have not been set up with MHS before

Provider Indiana Medicaid # *

Group/Facility Name *

Group Indiana Medicaid # *

Practitioner Name

First Name *

Last Name *

Practitioner Gender *

Male Female N/A (Facility)

Practitioner Email Address

Tax ID # *

Individual NPI # *

Group NPI # *

Primary Taxonomy Code *

Specialty

Billing Address

Street Address

City

Zip / Postal Code

State

Billing Address Phone

Service Location Address

Street Address

City

Zip / Postal Code

State

Service Location Phone

Contact First Name *

Contact Last Name *

Contact Title *

Contact Phone *

Contact Email *