IHCP MCE Hospital Ancillary Provider Enrollment and Credentialing 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the appropriate Indiana Health Coverage Programs (IHCP) managed care program(s) that apply to your enrollment. Indicate whether this is a new enrollment or an update.
3. Fill in the demographic information section, including your DBA Name or Legal Name, Entity Name, IHCP Provider ID, and contact details. Ensure all entries are legible.
4. Complete the billing information if it differs from the demographic section. Provide necessary details such as payee name and contact information.
5. Answer the disclosure questions honestly. If applicable, provide additional details on a separate sheet as instructed.
6. Review the attestation and authorization section carefully before signing and dating the form to confirm accuracy and completeness.

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