Home
Forms Library
Provider Forms - Indiana health plans

Provider Forms - Indiana health plans 2025

Provider Forms - Indiana health plans Preview on Page 1

Show details

4.4 out of 5

38 votes

The document is the IHCP MCE Provider Enrollment and Credentialing Form, version 2.3, dated March 2024. It is designed for enrolling hospitals, home health agencies, and other non-practitioner providers in Indiana Health Coverage Programs managed care entities. The form requires detailed demographic and billing information, accessibility details, liability coverage information, and responses to disclosure questions. It also includes an attestation section for authorization to release credentialing information and emphasizes the importance of truthful submissions.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to rapidly redact Provider Forms - Indiana health plans online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Dochub is the greatest editor for changing your documents online. Follow this straightforward guide to edit Provider Forms - Indiana health plans in PDF format online at no cost:

Register and sign in. Create a free account, set a secure password, and proceed with email verification to start managing your templates.
Add a document. Click on New Document and choose the form importing option: add Provider Forms - Indiana health plans from your device, the cloud, or a secure link.
Make changes to the template. Utilize the top and left panel tools to edit Provider Forms - Indiana health plans. Insert and customize text, pictures, and fillable areas, whiteout unnecessary details, highlight the important ones, and comment on your updates.
Get your paperwork done. Send the form to other people via email, create a link for quicker file sharing, export the template to the cloud, or save it on your device in the current version or with Audit Trail added.

Try all the advantages of our editor today!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is proof of income for Medicaid in Indiana?

Preferred documentation is the most recent three (3) consecutive paycheck stubs for all household members. Other acceptable documentation is an employers letter (on company letterhead) signed and dated, showing how much you earn and how often received.

What is a provider enrollment form?

In the most basic terms, provider enrollment (sometimes referred to as payer enrollment) is the process through which healthcare providers apply to be included in a health insurance network. As an in-network provider, you will be able to treat patients who carry that insurance and be reimbursed for your services.

What is Indianas health plan called?

The Healthy Indiana Plan (HIP) is an insurance program offered by the state of Indiana. HIP gives health care to low-income adults. Go to .in.gov/fssa/hip to learn more about HIP income limits.

What do I need to bring with me to get Medicaid?

Your Medicaid office may ask you to show the following: Proof of date of birth (e.g., birth certificate) Proof U.S. citizenship or lawful residence (e.g., passport, drivers license, birth certificate, green card, employment authorization card)

What documents do you need for Medicaid in Indiana?

INFORMATION REQUIRED TO COMPLETE THE INDIANA MEDICAID APPLICATION Names and dates of birth. Social Security Numbers. Income from jobs or training. Benefits you get now (or got in the past), such as Social Security, Supplemental Security Income (SSI), veterans benefits, or child support.