IHCP Provider Enrollment Type and Specialty Matrix

Sep 20, 2026

Uploaded by Mabel

IHCP Provider Enrollment Type and Specialty Matrix provides step-by-step guidance for Indiana Health Coverage Programs providers to enroll using the IHCP online application, portal, or mail-based enrollment packet selection. It explains that provider types and specialties can be submitted through the IHCP Provider Healthcare Portal, while mail applicants download the appropriate packet by provider type, specialty, and classification. The matrix details document requirements for hospital-related provider types and specialties, comparing in-state versus out-of-state requirements and listing items such as provider agreements, W-9 forms, licenses, accreditation, CLIA certificates, Medicare numbers, application fees, and recertification or risk screening conditions.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages48

Reading Time2 h 1 min

AccessFree to download

Provider Enrollment Overview

Enrollment Channels and Where to Apply

Online and Mail Packet Selection

Document Requirements Matrix

In-State vs Out-of-State Requirements

Hospital Provider Types and Specialties

Acute Care (Specialty 010)

Psychiatric (Specialty 011)

Rehabilitation (Specialty 012)

IHCP Provider Enrollment Type and Specialty Matrix Step-by-step instructions for enrolling as an Indiana Health Coverage Programs (IHCP) provider are available on the Complete an IHCP Provider Enrollment Application webpage. All provider types and specialties listed in this document) can apply online through the IHCP Provider Healthcare Portal. Providers who choose to enroll by mail can go to the IHCP Provider Enrollment Packet Finder webpage, select the applicable provider type, specialty and classification, and download the appropriate enrollment packet. For more information about enrolling as an Indiana Medicaid provider, see the Provider Enrollment IHCP provider reference module. All links are accessible from the IHCP provider website at [in.gov/medicaid/providers](in.gov/medicaid/providers). | Provider Type Code & Description | Provider Specialty Code & Description | In-State Provider Document Requirements | Out-of-State Provider Document Requirements | | | --- | --- | --- | --- | --- | | 01 – Hospital | 010 – Acute Care | • IHCP Hospital and Facility provider enrollment packet or online application, which includes:
○ Provider Agreement
○ Federal W-9 form
• Copy of hospital license from the Indiana Department of Health (IDOH)
• Must demonstrate compliance with federal Conditions of Participation, either through accreditation or IDOH survey
Note: The IDOH transmits the certification directly to the IHCP Provider Enrollment Unit after the provider completes the survey process. The provider does not submit IDOH certification documentation to the IHCP;
however, the provider does need to submit a copy of the IDOH license.
• Copy of Clinical Laboratory Improvement Amendments (CLIA) certificate, if applicable
• Medicare number required for each service location
• Application fee required ~~1~~ | •
•
•
•
•
• | IHCP Hospital and Facility provider enrollment packet or online application, which includes:
○ Provider Agreement
○ Federal W-9 form
Copy of hospital license or accreditation from appropriate state ~~3~~
Copy of Clinical Laboratory Improvement Amendments (CLIA) certificate, if applicable
Medicare number required for each service location Proof of participation in own state’s Medicaid program, if enrolled
Application fee required ~~1~~ | 1 Application fee required – Can be satisfied by paying application fee in another state or to Medicare. Providers may request a waiver of the application fee due to financial hardship. Proof of payment or proof of approved hardship waiver is required. For more information, see the Provider Enrollment Application Fee webpage. 2 Fingerprint and background check required – Can be satisfied if performed as part of a Medicaid enrollment in another state or if Medicare enrolled. Proof of fingerprinting and background check performed is required. For more information, see the Provider Enrollment Risk Levels and Screening webpage. 3 Recertification required – For indicated credentials, currently enrolled IHCP providers must submit updated documentation to the IHCP before the expiration date of the credential on file to retain their IHCP eligibility. For more information, see the Recertify Your Enrollment Credentials webpage. | Provider Type Code & Description | Provider Specialty Code & Description | In-State Provider Document Requirements | Out-of-State Provider Document Requirements | | | --- | --- | --- | --- | --- | | 01 – Hospital | 011 – Psychiatric
(Freestanding or with independent organizational structure; includes institutions for mental disease [IMDs]) | • IHCP Hospital and Facility provider enrollment packet or online application, which includes:
○ Provider Agreement
○ Federal W-9 form
• Copy of Division of Mental Health and Addiction (DMHA) Private Mental Health Facility license ~~3~~
• Must demonstrate compliance with federal Conditions of Participation, either through accreditation or IDOH surv

FAQs

How do providers enroll in the IHCP program?

Providers can enroll online through the IHCP Provider Healthcare Portal using the provider type and specialty listed for this matrix. Providers who enroll by mail use the IHCP Provider Enrollment Packet Finder to select the applicable provider type, specialty, and classification, then download the correct enrollment packet.

Where can providers access IHCP enrollment links and guidance?

Enrollment resources are accessible from the IHCP provider website at in.gov/medicaid/providers.

What documents are typically required for IHCP hospital enrollment in Indiana versus out-of-state?

The matrix lists required items such as the provider agreement, a federal W-9 form, and copies of relevant licenses or accreditation, plus CLIA certificates when applicable and Medicare numbers for each service location. Out-of-state requirements also include proof of participation in the provider’s own state’s Medicaid program when enrolled.

Sep 20, 2026

Uploaded by Mabel

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