To join an Indiana Medicaid managed care network as an individual provider, you complete the IHCP MCE Practitioner Enrollment Form and send a signed copy to each Managed Care Entity you want to work with. Every MCE runs its own credentialing review, so one form does not cover all of them. The current version (2.2, revised March 2023) runs four pages and is available at in.gov/medicaid/providers.
What to Gather Before You Open the Form
Most delays come from identifier mismatches between what you type and what federal or state systems already show. Pulling everything together first is faster than fixing it later.
- Your individual (Type 1) ten-digit NPI, plus any group Type 2 NPI and its taxonomy codes if you bill through an entity.
- Social Security Number and date of birth.
- Taxonomy codes for every area you practice in.
- Your Indiana professional license number, exactly as the licensing board has it on file.
- DEA registration and Indiana Controlled Substance Registration (CSR) numbers, if you prescribe controlled substances.
- Your EIN if you bill through any entity other than yourself as a sole proprietor; otherwise your SSN. This ties to your W-9.
- Your IHCP Provider ID if you already have one. Leave it blank if you are new to Indiana Medicaid.
- A current CAQH Provider Data Portal profile.
The CAQH piece catches first-time applicants off guard. Indiana requires every practitioner enrolling with an MCE to maintain a CAQH profile (formerly ProView), and MCEs pull from it to verify education, training, malpractice history, and hospital affiliations. If you already have an account, add each MCE you plan to apply to as an authorized plan. If you do not, register at proview.caqh.org and finish the profile before you submit the enrollment form. An incomplete or outdated CAQH record will stall credentialing even if your paper form is perfect.
Filling Out the Form Section by Section
The four pages feed different parts of each MCE’s credentialing and claims systems. Accuracy matters more than speed.
Practitioner Data
Pages one and two collect your personal and professional identifiers: name, degree (MD, DO, DMD, DPM, CRNA, NP, CNM, or other), SSN, date of birth, gender, NPI, taxonomy codes, license numbers, DEA and CSR numbers, and CAQH number. You also choose your enrollment category, such as Primary Medical Provider (PMP) with a member panel, physician specialist, nurse practitioner supporting a PMP, behavioral health provider, certified midwife, or prenatal care coordinator.
If you enroll as a PMP, set your maximum panel size for each program you will serve (Hoosier Healthwise, HIP, Hoosier Care Connect, and PathWays) and indicate any age restrictions. Options range from no restriction to specific bands like 0–17 or 21 and older. OB/GYN PMPs also choose a scope of practice designation.
Primary Practice Information
Enter your practice group name, service location address, office phone and fax, office contact and email, county, group NPI, group IHCP Provider ID, taxonomy codes, and Medicare group number. You list office hours and say whether the MCE should assign members to this location.
A checklist below the address covers building, parking, and restroom accessibility; TTY and American Sign Language availability; services for mental or physical impairments; public transportation access; evening and weekend hours; and whether you serve children with special healthcare needs. These answers populate the MCE’s provider directory, so mark only what actually applies. An inaccurate directory listing can trigger compliance issues later.
Pay-To and Mailing Information
This section captures your billing name, Taxpayer Identification Number, billing address, and billing contact. If your mailing address differs from your service location, use the separate mailing fields. Errors here delay claims payments more than mistakes anywhere else on the form.
Other Practice Locations
Page three repeats the primary practice fields for each additional site. Every location needs its own accessibility and service checklist.
Disclosures You Cannot Skip
Federal rules require every Medicaid provider to disclose ownership, family relationships, and criminal history. These are not optional sections.
Under 42 CFR 455.104, you must identify every individual or organization that holds a 5 percent or greater ownership or controlling interest in your practice. For each, give the name, address, date of birth (for individuals), and SSN or EIN. You also disclose whether any of those owners are related as spouses, parents, children, or siblings.1eCFR. 42 CFR Part 455 Subpart B – Disclosure of Information by Providers and Fiscal Agents
Under 42 CFR 455.106, you must disclose anyone with ownership or controlling interest, or any agent or managing employee, who has been convicted of a criminal offense related to Medicare, Medicaid, or Title XX. There is no lookback limit on this disclosure.2eCFR. 42 CFR 455.106 – Disclosure by Providers: Information on Persons Convicted of Crimes
The form also asks directly whether the practitioner or practice has ever been excluded from Medicaid or Medicare, with space for an explanation and dates. Incomplete or dishonest answers can lead to denial or termination of an existing enrollment. Separately, MCEs and the state screen applicants against the Office of Inspector General’s List of Excluded Individuals and Entities (LEIE). Anyone on the LEIE cannot be paid by any federal healthcare program, and the OIG recommends practices run their own LEIE checks on employees and owners because hiring an excluded individual can trigger civil monetary penalties.3Office of Inspector General. Exclusions
Choosing Which MCEs to Submit To
You send a separate completed form to each MCE you want to join. Enrolling with Anthem does not enroll you with MHS, and so on. Each MCE participates in a different mix of Indiana’s managed care programs:
- Anthem — HIP, Hoosier Care Connect, Hoosier Healthwise, and PathWays for Aging. 844-284-1798 / anthem.com
- CareSource — HIP and Hoosier Healthwise. 844-607-2831 / caresource.com
- Humana — PathWays for Aging. 866-274-5888 / humana.com
- Managed Health Services (MHS) — HIP, Hoosier Care Connect, and Hoosier Healthwise. 877-647-4848 / mhsindiana.com
- UnitedHealthcare — Hoosier Care Connect and PathWays for Aging. 877-610-9785 / UHCprovider.com/INcommunityplan
Practitioners who want wide coverage across Indiana’s Medicaid population usually enroll with at least Anthem and MHS, since those two cover the most programs. If you focus on aging populations, Humana and UnitedHealthcare both participate in PathWays alongside Anthem.
How to Submit
Once every section is complete and you have signed the attestation on page four, send a copy to each MCE you selected.4Indiana Health Coverage Programs. IHCP MCE Instructions for Enrollment and Credentialing Submission methods vary. Some MCEs accept mailed applications; others require secure upload through their provider portals. Call each MCE at the number above to confirm the current method before you send anything.
One boundary to flag: the MCE form is not the same as general IHCP enrollment. You first need to be enrolled with Indiana Medicaid through the Provider Healthcare Portal at portal.indianamedicaid.com. The MCE practitioner form adds you to specific managed care networks on top of that base enrollment.
What Happens After You Submit
Each MCE confirms receipt and starts credentialing. Under Indiana’s credentialing standards, an MCE has 30 calendar days from receipt of a complete application to finish the review, and credentialed providers are loaded into the claims system within seven business days of approval. If an MCE does not reach a decision on a clean application within 15 calendar days and this is your first time applying to that MCE, it must treat you as provisionally credentialed while the review continues.5Optum. Summary of Indiana Medicaid Provider Credentialing Policy
During the review, the MCE pulls your CAQH profile to verify education, training, board certifications, malpractice claims, and hospital affiliations, and checks you against state licensing databases and federal exclusion lists. If anything is missing in CAQH, the MCE will issue a documentation request and your 30-day clock effectively restarts.
Approval comes as a formal notice from the MCE confirming active status, with an effective date typically set to the day the MCE received your complete application. You can then treat members in that MCE’s programs and submit claims. If an application is denied, the notice explains why. Common causes are mismatched NPI or license data, an expired CAQH profile, unresolved malpractice history, or a match on an exclusion database. You can usually correct the issue and reapply.
Keeping Your Enrollment Active
CAQH is not a one-time setup. Providers must re-attest that their information is still current on a regular schedule, typically every 120 days. A lapsed profile can block re-credentialing, which can interrupt your network participation and your payments. Update CAQH right away when you change addresses, add a location, change malpractice coverage, or earn a new certification, rather than waiting for the next re-attestation.6CAQH. For Providers
Enrollment itself also expires. Federal rules require Medicaid providers to revalidate at intervals of no more than five years, and Indiana applies a three-year cycle to some provider types. The state will notify you when revalidation is due, but tracking the date yourself is worth the effort. Providers who miss the window are removed from the program, claims payments stop the day after the deadline, and retroactive reinstatement is generally not permitted under federal regulations. The result is an enrollment gap during which you cannot bill for services.