Indiana Medicaid: Providers: Forms - IN.gov
3 days ago · Note: Many of these forms have been integrated into the IHCP Provider Healthcare Portal (IHCP Portal) and, therefore, are not required for transactions conducted via the IHCP …
Complete an IHCP Provider Enrollment Application - IN.gov
Providers are encouraged to use the IHCP Provider Healthcare Portal (IHCP Portal) to enroll in the IHCP, add a service location, report a change of ownership, revalidate or update provider …
IHCP Prior Authorization Request Form Version 9.2, July 2024 Page 2 of 2 Notes: PLEASE NOTE: Your request MUST include medical documentation to be reviewed for medical …
This form is used to enroll participating practitioners with any of the Indiana Health Coverage Programs (IHCP) managed care entities (MCEs). Note: Home- and Community-Based …
IHCP providers wishing to enroll with one or more of the MCEs must complete the following enrollment and credentialing process. All applicable forms must be completed and submitted …
Programs (IHCP) or the designated personal representative must complete this form. If the personal representative is the only signature, the form must be notarized.
This form is used to enroll participating facilities such as hospitals, home health agencies, and other nonpractitioner providers with any of the Indiana Health Coverage Programs (IHCP) …
(universal prior authorization form) Note: These instructions should also be followed when completing the Residential/Inpatient Substance Use Disorder Treatment Prior Authorization …
Complete an IHCP Provider Application page at in.gov.medicaid/providers. • OPR organizations – Practitioners within your organization who might order, prescribe, or refer services or supplies …
claim form. If additional attachments need to be submitted, those attachments should be placed behind this form. Paper claim forms and all relevant attachments should be mailed to the …