IHCP MATRIX FOR PROVIDER ENROLLMENT TYPES AND SPECIALTIES

IHCP Provider Enrollment
Type and Specialty Matrix

All provider types and specialties listed in this document as eligible to enroll in the Indiana Health Coverage Programs (IHCP) can apply online through the
IHCP Provider Healthcare Portal. Providers who choose to enroll by mail can go to the Complete an IHCP Provider Enrollment Application webpage, select the
applicable provider type, 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 above are accessible from the IHCP provider website at in.gov/medicaid/providers.

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 010 – Acute Care • IHCP Hospital and Facility provider enrollment packet or • IHCP Hospital and Facility provider enrollment packet or
online application, which includes: online application, which includes:
01 – Hospital ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form
01 – Hospital
• Copy of Indiana Department of Health (IODH) certification • Copy of license from appropriate state
• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable (CLIA) certificate, if applicable
• Medicare number required for each service location • Medicare number required for each service location
• Application fee required 1 • Proof of participation in own state’s Medicaid program, if

011 – Psychiatric Facility • IHCP Hospital and Facility provider enrollment packet (or enrolled
online application), which includes: • Application fee required 1
(Freestanding or with
independent organizational ○ Provider Agreement • IHCP Hospital and Facility provider enrollment packet or
structure; includes institutions ○ Federal W-9 form online application, which includes:
for mental disease [IMDs]) ○ Provider Agreement

• Copy of Division of Mental Health and Addiction (DMHA) ○ Federal W-9 form
Private Mental Health Facility license or Indiana
Department of Health (IDOH) certification • Copy of appropriate license from appropriate state
• Copy of Clinical Laboratory Improvement Amendments
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable (CLIA) certificate, if applicable
• Medicare number required for each service location
• Medicare number required for each service location • Proof of participation in own state’s Medicaid program,
• Application fee required 1
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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 012 – Rehabilitation • IHCP Hospital and Facility provider enrollment packet or • IHCP Hospital and Facility provider enrollment packet or
(Distinct part or unit) online application, which includes: online application, which includes:
01 – Hospital ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form

01 – Hospital
• Copy of Indiana Department of Health (IDOH) certification • Copy of license from appropriate state
• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable (CLIA) certificate, if applicable
• Medicare number required for each service location • Medicare number required for each service location
• Application fee required 1 • Proof of participation in own state’s Medicaid program,

013 – Long Term Acute Care (LTAC) • IHCP Hospital and Facility provider enrollment packet or if enrolled
online application (indicate update to a current provider • Application fee required 1
number), which includes:
Out-of-state providers with this type and specialty are
○ Provider Agreement ineligible for IHCP provider enrollment.
○ Federal W-9 form

• Copy of Indiana Department of Health (IDOH) license
complying with IC 16-21 for LTAC

• Copy of Centers for Medicare & Medicaid Services (CMS)
LTAC approval letter

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number required for each service location
• 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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 020 – Ambulatory Surgical Center • IHCP Hospital and Facility provider enrollment packet or • IHCP Hospital and Facility provider enrollment packet or
(ASC) online application, which includes: online application, which includes:
02 – Ambulatory ○ Provider Agreement ○ Provider Agreement
Surgical Center ○ Federal W-9 form ○ Federal W-9 form

03 – Extended Care • Copy of Indiana Department of Health (IDOH) certification • Copy of license from appropriate state
Facility • Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable (CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Application fee required 1 • Proof of participation in own state’s Medicaid program,

030 – Nursing Facility • IHCP Hospital and Facility provider enrollment packet or if enrolled
online application, which includes: • Application fee required 1
031 – Intermediate Care Facility ○ Provider Agreement
for Individuals with Intellectual ○ Federal W-9 form Out-of-state providers with this type and specialty are
Disabilities (ICF/IID) ineligible for IHCP provider enrollment.
• Copy of Indiana Department of Health (IDOH) certification
032 – Pediatric Nursing Facility • Copy of Clinical Laboratory Improvement Amendments

033 – Residential Care Facility (CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• 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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 034 – Psychiatric Residential • IHCP Hospital and Facility provider enrollment packet or Out-of-state providers with this type and specialty are
Treatment Facility (PRTF) online application, which includes: ineligible for IHCP provider enrollment.
03 – Extended Care ○ Provider Agreement
Facility ○ Federal W-9 form Out-of-state providers with this type and specialty are
ineligible for IHCP provider enrollment.
04 – Rehabilitation 040 – Rehabilitation Facility • Copy of Indiana Department of Health (IDOH) certification
Facility • Indiana Department of Child Services (DSC) residential

child-care license for a private, secure care facility
• Copy of Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) or Council on Accreditation (COA)
credentials
• Attestation letter for facility compliance
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• Application fee required 1

• IHCP Hospital and Facility provider enrollment packet or
online application, which includes:
○ Provider Agreement
○ Federal W-9 form

• Copy of Indiana Department of Health (IDOH) certification
• Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• 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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 041 – Comprehensive Outpatient • IHCP Group and Clinic provider enrollment packet or online Out-of-state providers with this type and specialty are
Rehabilitation Facility (CORF) application, which includes: ineligible for IHCP provider enrollment.
04 – Rehabilitation ○ Provider Agreement
Facility 050 – Home Health Agency ○ Federal W-9 form Out-of-state providers with this type and specialty are
ineligible for IHCP provider enrollment.
05 – Home Health • Copy of Indiana Department of Health (IDOH) certification
Agency • Copy of license from the Indiana Professional Licensing

Agency (IPLA) for rendering providers linked to the group
• Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable
• Medicare number required for each service location
• Application fee required 1

Note: Per CMS requirements – Facility must have on staff:
physician and HSPP mental health provider and physical
therapist

• IHCP Hospital and Facility provider enrollment packet or
online application, which includes:
○ Provider Agreement
○ Federal W-9 form

• Copy of Indiana Department of Health (IDOH) license
• Copy of Clinical Laboratory Improvement Amendments

(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• Application fee required 1
• Fingerprinting and background check required 2

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 060 – Hospice • IHCP Hospital and Facility provider enrollment packet or Out-of-state providers with this type and specialty are
online application, which includes: ineligible for IHCP provider enrollment.
06 – Hospice ○ Provider Agreement
○ Federal W-9 form Out-of-state providers with this type and specialty are
08 – Clinic 080 – Federally Qualified Health ineligible for IHCP provider enrollment.
Center (FQHC) • Copy of hospice license from the Indiana Department of
Health (IDOH)
Note: For state-licensed hospitals, health facilities
and home health agencies, an IDOH approval to
operate a hospice program is acceptable in lieu of a

hospice license.

• Copy of a Certification and Transmittal (C&T) for each
hospice office location
Note: The C&T is forwarded to the IHCP Provider
Enrollment Unit by the IDOH; it is not submitted by
the provider

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number required for each service location
• Application fee required 1

• IHCP Group and Clinic provider enrollment packet or online
application, which includes:
○ Provider Agreement
○ Federal W-9 form

• Copy of CMS approval letter verifying FQHC enrollment for
each location

• Copy of license from the Indiana Professional Licensing
Agency (IPLA) for rendering providers linked to the group

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare
• 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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 081 – Rural Health Clinic (RHC) • IHCP Group and Clinic provider enrollment packet or online Out-of-state providers with this type and specialty are
application, which includes: ineligible for IHCP provider enrollment.
08 – Clinic ○ Provider Agreement
○ Federal W-9 form • IHCP Group and Clinic provider enrollment packet or online
08 – Clinic 082 – Medical Clinic application, which includes:
• Copy of license from the Indiana Professional Licensing ○ Provider Agreement
Agency (IPLA) for rendering providers linked to the group ○ Federal W-9 form

• Copy of CMS approval letter verifying RHC enrollment for • Copy of license from appropriate state for rendering
each location, if applicable providers linked to the group

• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable (CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare

• Application fee required 1 • Proof of participation in own state’s Medicaid program,

• IHCP Group and Clinic provider enrollment packet or online if enrolled
application, which includes:
○ Provider Agreement
○ Federal W-9 form

• Copy of license from the Indiana Professional Licensing
Agency (IPLA) for rendering providers linked to the group

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 083 – Family Planning Clinic • IHCP Group and Clinic provider enrollment packet or online • IHCP Group and Clinic provider enrollment packet or online

application, which includes: application, which includes:
08 – Clinic ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form
08 – Clinic 084 – Nurse Practitioner Clinic
• Copy of license from the Indiana Professional Licensing • Copy of license from appropriate state for rendering
Agency (IPLA) for rendering providers linked to the group providers linked to the group

• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable (CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
• IHCP Group and Clinic provider enrollment packet or online
application, which includes: if enrolled
○ Provider Agreement
○ Federal W-9 form • IHCP Group and Clinic provider enrollment packet or online
application, which includes:
• Copy of license from the Indiana Professional Licensing ○ Provider Agreement
Agency (IPLA) for rendering providers linked to the group ○ Federal W-9 form

• Copy of Clinical Laboratory Improvement Amendments • Copy of license from appropriate state for rendering
(CLIA) certificate, if applicable providers linked to the group

• Medicare number, if enrolled in Medicare • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,

if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 086 – Dental Clinic • IHCP Group and Clinic provider enrollment packet or online • IHCP Group and Clinic provider enrollment packet or online
application, which includes: application, which includes:
08 – Clinic ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form
08 – Clinic 087 – Therapy Clinic
• For a sole proprietorship, partnership, or professional • For a sole proprietorship, partnership, or professional
services corporation, all entities with an ownership or control services corporation, all entities with an ownership or control
interest, as disclosed on the provider enrollment interest, as disclosed on the provider enrollment
application, must have dental licenses application, must have dental licenses

• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable (CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,

Note: A dental practice must be owned by a dentist.
if enrolled
• IHCP Group and Clinic provider enrollment packet or online
application, which includes: Note: A dental practice must be owned by a dentist.
○ Provider Agreement
○ Federal W-9 form • IHCP Group and Clinic provider enrollment packet or online
application, which includes:
• Copy of Clinical Laboratory Improvement Amendments ○ Provider Agreement
(CLIA) certificate, if applicable ○ Federal W-9 form

• Medicare number, if enrolled in Medicare • Copy of Clinical Laboratory Improvement Amendments
• Application fee required 1 (CLIA) certificate, if applicable

Note: Per CMS requirements – Clinic must have two enrolled • Medicare number, if enrolled in Medicare
physicians plus one or more therapists. • Proof of participation in own state’s Medicaid program,

if enrolled
• Application fee required 1

Note: Per CMS requirements – Clinic must have two enrolled
physicians plus one or more therapists.

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 088 – Birthing Center • IHCP Group and Clinic provider enrollment packet or online • IHCP Group and Clinic provider enrollment packet or online
application, which includes: application, which includes:
08 – Clinic 090 – Pediatric Nurse Practitioner ○ Provider Agreement ○ Provider Agreement
091 – Obstetric Nurse Practitioner ○ Federal W-9 form ○ Federal W-9 form
09 – Advanced 092 – Family Nurse Practitioner
Practice Registered 093 – Clinical Nurse Specialist • Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
Nurse 094 – Certified Registered Nurse (CLIA) certificate, if applicable (CLIA) certificate, if applicable
Anesthetist (CRNA)
095 – Certified Nurse Midwife • Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
Note: Per CMS requirements – Clinic must have a physician
and/or midwife on staff. if enrolled

• IHCP provider enrollment packet or online application for Note: Per CMS requirements – Clinic must have a physician
your classification, which includes: and/or midwife on staff.
○ Provider Agreement
○ Federal W-9 form • IHCP provider enrollment packet or online application for
your classification, which includes:
• Copy of license from Indiana Professional Licensing Agency ○ Provider Agreement
(IPLA) ○ Federal W-9 form

• Copy of Nurse Practitioner (NP) certification from • Copy of license from the appropriate state
accredited NP certifying organization • If applicable, copy of license from Indiana Professional

• Copy of Clinical Laboratory Improvement Amendments Licensing Agency (IPLA) with the Telemedicine Provider
(CLIA) certificate, if applicable Certification
• Copy of Nurse Practitioner (NP) certification from
• Medicare number, if enrolled in Medicare accredited NP certifying organization
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 100 – Physician Assistant • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
your classification, which includes: your classification, which includes:
10 – Physician ○ Provider Agreement ○ Provider Agreement
Assistant ○ Federal W-9 form ○ Federal W-9 form

11 – Behavioral Health 110 – Outpatient Mental Health • Copy of license from Indiana Professional Licensing Agency • Copy of license from the appropriate state

(IPLA) • If applicable, copy of license from Indiana Professional
Provider Clinic
• Copy of Clinical Laboratory Improvement Amendments Licensing Agency (IPLA) with the Telemedicine Provider
(CLIA) certificate, if applicable Certification
• Copy of Clinical Laboratory Improvement Amendments
• Medicare number, if enrolled in Medicare (CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• IHCP Group and Clinic provider enrollment packet or online • Proof of participation in own state’s Medicaid program,
application, which includes: if enrolled
○ Provider Agreement
○ Federal W-9 form Out-of-state providers with this type and specialty are
○ Outpatient Mental Health Addendum ineligible for IHCP provider enrollment.

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider

Code & Code & Description Document Requirements Document Requirements

Description 111 – Community Mental Health • IHCP Group and Clinic provider enrollment packet or online Out-of-state providers with this type and specialty are
Center (CMHC) application, which includes: ineligible for IHCP provider enrollment.
11 – Behavioral ○ Provider Agreement
Health Provider 114 – Health Service Provider in ○ Federal W-9 form • IHCP provider enrollment packet or online application for
Psychology (HSPP) ○ Outpatient Mental Health Addendum your classification, which includes:
11 – Behavioral ○ Provider Agreement
Health Provider 115 – Adult Mental Health and • Copy of CMHC certification from FSSA Division of Mental ○ Federal W-9 form
Habilitation (AMHH) Provider Health and Addiction (DMHA)
11 – Behavioral • Copy of license from appropriate state
Health Provider • Copy of Clinical Laboratory Improvement Amendments • Medicare number, if enrolled in Medicare
(CLIA) certificate, if applicable • Proof of participation in own state’s Medicaid program,

• Medicare number, if enrolled in Medicare if enrolled
• Application fee required 1 Out-of-state providers with this type and specialty are
ineligible for IHCP provider enrollment.
• IHCP provider enrollment packet or online application for
your classification, which includes:
○ Provider Agreement
○ Federal W-9 form

• Copy of license from Indiana Professional Licensing Agency
(IPLA)

• Medicare number, if enrolled in Medicare

Not a stand-alone specialty; AMHH can only be added as a
secondary specialty to a CMHC enrollment (provider type 11,
specialty 111).

The following additional documentation is required when
adding this specialty to a CMHC enrollment:
• Copy of AMHH certification from FSSA Division of Mental

Health and Addiction (DMHA)

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 611 – Child Mental Health • IHCP Group and Clinic provider enrollment packet or online Out-of-state providers with this type and specialty are
Wraparound (CMHW) Provider application, which includes: ineligible for IHCP provider enrollment.
11 – Behavioral ○ Provider Agreement
Health Provider ○ Federal W-9 form Out-of-state providers with this type and specialty are
○ Outpatient Mental Health Addendum ineligible for IHCP provider enrollment.
11 – Behavioral 612 – Behavioral and Primary
Health Provider Healthcare Coordination (BPHC) • Copy of certification from FSSA Division of Mental Health Out-of-state providers with this type and specialty are
Provider and Addiction (DMHA) ineligible for IHCP provider enrollment.

11 – Behavioral 613 – MRO Clubhouse • Medicare number, if enrolled in Medicare

Health Provider • Application fee required 1
(For psychosocial
rehabilitation services) Not a stand-alone specialty; BPHC can only be added as a
secondary specialty to a CMHC enrollment (provider type 11,
specialty 111).
The following additional documentation is required when
adding this specialty to a CMHC enrollment:
• Copy of BPHC certification from FSSA Division of Mental

Health and Addiction (DMHA)

• IHCP Rendering provider enrollment packet or online
application, which includes:
○ Rendering Provider Agreement
○ IHCP MRO Clubhouse Provider Enrollment
Addendum

• Copy of Psychosocial Rehabilitation Service Provider
certification from the FSSA Division of Mental Health and
Addiction (DMHA)

Note: This specialty can only be added as a rendering provider
contracted with (and linked to) an IHCP-enrolled CMHC
(provider type 11, specialty 111).

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

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IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 615 – Applied Behavior Analysis • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
(ABA) Therapist your classification, which includes: your classification, which includes:
11 – Behavioral Health ○ Provider Agreement ○ Provider Agreement
Provider ○ Federal W-9 form ○ Federal W-9 form

11 – Behavioral Health 616 – Licensed Psychologist • Copy of Behavior Analyst Certification Board (BACB) • Copy of license from the appropriate state agency
Provider certification as a Board Certified Behavior Analyst (BCBA), • Copy of Clinical Laboratory Improvement Amendments
Board Certified Behavior Analyst-Doctoral (BCBA-D) , or
professional license as Health Service Provider in (CLIA) certificate, if applicable
Psychology (HSPP) • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable if enrolled

• Medicare number, if enrolled in Medicare • IHCP provider enrollment packet or online application for
your classification, which includes:
• IHCP provider enrollment packet or online application for ○ Provider Agreement
your classification, which includes: ○ Federal W-9 form
○ Provider Agreement
○ Federal W-9 form • Copy of Psychologist license from the appropriate state
agency

• Copy of Psychologist license
• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable
(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,

if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 14 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 617 – Licensed Independent • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
Practice School Psychologist your classification, which includes: your classification, which includes:
11 – Behavioral Health ○ Provider Agreement ○ Provider Agreement
Provider ○ Federal W-9 form ○ Federal W-9 form

11 – Behavioral Health 618 – Licensed Clinical Social • Copy of School Services – School Psychologist license • Copy of School Services – School Psychologist license
through Indiana Department of Education (IDOE) through the appropriate state’s department of education

Provider Worker (LCSW) Note: The individual must be recognized by IDOE as
an Initial Practitioner, a Proficient Practitioner, or an Note: The individual must be recognized by their state’s
Accomplished Practitioner. Department of Education as an Initial Practitioner, a
Proficient Practitioner, or an Accomplished Practitioner.
• Documentation that the individual maintains an
Independent Practice Endorsement (IPE) • Documentation that the individual maintains an
Independent Practice Endorsement (IPE)
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare
• Medicare number, if enrolled in Medicare
• IHCP provider enrollment packet or online application for • Proof of participation in own state’s Medicaid program,
your classification, which includes:
○ Provider Agreement if enrolled
○ Federal W-9 form
• IHCP provider enrollment packet or online application for
• Copy of Clinical Social Worker license your classification, which includes:
• Copy of Clinical Laboratory Improvement Amendments ○ Provider Agreement
○ Federal W-9 form
(CLIA) certificate, if applicable
• Medicare number, if enrolled in Medicare • Copy of Clinical Social Worker license from the appropriate
state agency

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,

if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 15 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 619 – Licensed Marriage and • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
Family Therapist (LMFT) your classification, which includes: your classification, which includes:
11 – Behavioral Health ○ Provider Agreement ○ Provider Agreement
Provider ○ Federal W-9 form ○ Federal W-9 form

11 – Behavioral Health 620 – Licensed Mental Health • Copy of Marriage & Family Therapist license • Copy of Marriage & Family Therapist license from the
• Copy of Clinical Laboratory Improvement Amendments appropriate state agency
Provider Counselor (LMHC)
(CLIA) certificate, if applicable • Copy of Clinical Laboratory Improvement Amendments
• Medicare number, if enrolled in Medicare (CLIA) certificate, if applicable

• IHCP provider enrollment packet or online application for • Medicare number, if enrolled in Medicare
your classification, which includes: • Proof of participation in own state’s Medicaid program,
○ Provider Agreement

○ Federal W-9 form if enrolled

• Copy of Mental Health Counselor license • IHCP provider enrollment packet or online application for
• Copy of Clinical Laboratory Improvement Amendments your classification, which includes:
○ Provider Agreement
(CLIA) certificate, if applicable ○ Federal W-9 form
• Medicare number, if enrolled in Medicare
• Copy of Mental Health Counselor license from the
appropriate state agency

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,

if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 16 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider

Code & Code & Description Document Requirements Document Requirements

Description 621 – Licensed Clinical Addiction • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
Counselor (LCAC) your classification, which includes: your classification, which includes:
11 – Behavioral Health ○ Provider Agreement ○ Provider Agreement
Provider ○ Federal W-9 form ○ Federal W-9 form

11 – Behavioral Health 835 – Opioid Treatment Program • Copy of Clinical Addiction Counselor license • Copy of Clinical Addiction Counselor license from the
Provider • Copy of Clinical Laboratory Improvement Amendments appropriate state agency

(CLIA) certificate, if applicable • Copy of Clinical Laboratory Improvement Amendments
• Medicare number, if enrolled in Medicare (CLIA) certificate, if applicable

• IHCP provider enrollment packet or online application for • Medicare number, if enrolled in Medicare
your classification, which includes: • Proof of participation in own state’s Medicaid program,
○ Provider Agreement
○ Federal W-9 form if enrolled

• Copy of Drug Enforcement Agency (DEA) registration Out-of-state providers with this type and specialty are
certificate ineligible for IHCP provider enrollment.

• Copy of Division of Mental Health and Addiction (DMHA)
Opioid Treatment Program certification

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 17 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 836 – Substance Use Disorder • IHCP Hospital and Facility provider enrollment packet or • IHCP Hospital and Facility provider enrollment packet or
(SUD) Residential Addiction online application, which includes: online application, which includes:
11 – Behavioral Health Treatment Facility
Provider ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form

• Provider must provide one of the following: • Provider must provide one of the following:

○ Copy of a Division of Mental Health and Addiction ○ Copy of a Division of Mental Health and Addiction
(DMHA) certification as a Sub-Acute Facility that (DMHA) certification as a Sub-Acute Facility that
includes an American Society of Addiction Medicine includes an American Society of Addiction Medicine
(ASAM) designation of offering either Level 3.1 or (ASAM) designation of offering either Level 3.1 or
Level 3.5 residential services Level 3.5 residential services

○ Proof of Department of Child Services (DCS) licensing ○ Proof of Department of Child Services (DCS) licensing
as a child care institution or private secure-care as a child care institution or private secure-care
institution with a DMHA Addiction Services Provider institution with a DMHA Addiction Services Provider

Regular Certification that includes an ASAM Regular Certification that includes an ASAM
designation of offering either Level 3.1 or Level 3.5 designation of offering either Level 3.1 or Level 3.5
residential services residential services.

• Facilities that have designations to offer both ASAM Level • Facilities that have designations to offer both ASAM Level
3.1 and Level 3.5 services within the facility must include 3.1 and Level 3.5 services within the facility must include
proof of both designations with their enrollment proof of both designations with their enrollment
application. application.

• Copy of Drug Enforcement Agency (DEA) registration • Copy of Drug Enforcement Agency (DEA) registration
certificate (optional) certificate (optional)

• Copy of Clinical Laboratory Improvement Amendments • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable (CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare • Medicare number, if enrolled in Medicare
• Application fee required 1
• 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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 18 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 120 – School Corporation • IHCP School Corporation provider enrollment packet or Out-of-state providers with this type and specialty are
online application, which includes: ineligible for IHCP provider enrollment.
12 – School 130 – County Health Department ○ Provider Agreement
Corporation ○ Federal W-9 form Out-of-state providers with this type and specialty are
140 – Podiatrist ineligible for IHCP provider enrollment.
13 – Public Health • Must be listed on the approved Indiana Department of
Agency Education’s school corporation list and charter school list • IHCP provider enrollment packet or online application for
your classification, which includes:
14 – Podiatrist • IHCP provider enrollment packet or online application for ○ Provider Agreement
your classification, which includes: ○ Federal W-9 form
○ Provider Agreement
○ Federal W-9 form • Copy of license from appropriate state
• If applicable, copy of license from Indiana Professional
• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable Licensing Agency (IPLA) with the Telemedicine Provider
Certification
• Application fee required 1 • Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable
• IHCP provider enrollment packet or online application for • Medicare number, if enrolled in Medicare
your classification, which includes: • Proof of participation in own state’s Medicaid program,
○ Provider Agreement if enrolled
○ Federal W-9 form

• Copy of license from Indiana Professional Licensing Agency

(IPLA)

• Copy of Clinical Laboratory Improvement Amendments
(CLIA) certificate, if applicable

• Medicare number, if enrolled in Medicare

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 19 of 41 Version 10.2; Aug. 15, 2023

IHCP Provider Enrollment
Type and Specialty Matrix

Provider Type Provider Specialty In-State Provider Out-of-State Provider
Code & Code & Description Document Requirements Document Requirements

Description 150 – Chiropractor • IHCP provider enrollment packet or online application for • IHCP provider enrollment packet or online application for
your classification, which includes: your classification, which includes:
15 – Chiropractor ○ Provider Agreement ○ Provider Agreement
○ Federal W-9 form ○ Federal W-9 form
17 – Therapist 170 – Physical Therapist
171 – Occupational Therapist • Copy of license from Indiana Professional Licensing Agency • Copy of license from appropriate state
173 – Speech/Hearing Therapist (IPLA) • Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
18 – Optometrist 180 – Optometrist • Medicare number, if enrolled in Medicare

if enrolled
• IHCP provider enrollment packet or online application for
your classification, which includes: • IHCP provider enrollment packet or online application for
○ Provider Agreement your classification, which includes:
○ Federal W-9 form ○ Provider Agreement
○ Federal W-9 form
• Copy of license from Indiana Professional Licensing Agency
(IPLA) • Copy of license from appropriate state
• Medicare number, if enrolled in Medicare
• Medicare number, if enrolled in Medicare • Proof of participation in own state’s Medicaid program,
• Application fee required if enrolling as a group 1
if enrolled
• IHCP provider enrollment packet or online application for • Application fee required if enrolling as a group 1
your classification, which includes:
○ Provider Agreement • IHCP provider enrollment packet or online application for
○ Federal W-9 form your classification, which includes:
○ Provider Agreement
• Copy of license from Indiana Professional Licensing Agency ○ Federal W-9 form
(IPLA)
• Copy of license from appropriate state
• Medicare number, if enrolled in Medicare • If applicable, copy of license from Indiana Professional

Licensing Agency (IPLA) with the Telemedicine Provider
Certification
• Medicare number, if enrolled in Medicare
• Proof of participation in own state’s Medicaid program,
if enrolled

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 at in.gov/medicaid/providers.

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 at in.gov/medicaid/providers.

IHCP Provider Enrollment Type and Specialty Matrix 20 of 41 Version 10.2; Aug. 15, 2023