Attachment A – Provider Type and Specialty Matrix August 2004
Indiana Health Coverage ProgramsProvider Type and Specialty Matrix
Version 4.0 August 2004
The following table lists provider type and specialty codes with the enrollment requirements and provider classification information
Note: Items in italics are not required.
Provider Type Codes / Provider Specialty Codes / In–State Provider Requirements / Out-of-State (OOS) Provider Requirements / Provider Classifications and Additional Processing Information /01 – Hospital / 010 – Acute Care
011 – Psychiatric (distinct part or unit)
012 – Rehabilitation (distinct part or unit) / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Copy of Indiana State Department of Health (ISDH) license
• Proof of Medicare participation
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Copy of license from appropriate state
• Proof of participation in own state’s Medicaid program / • Can only be enrolled as a billing provider, cannot be a group with members
• Certificate and Transmittal (C&T) sent directly to EDS from ISDH is required for Indiana providers before enrollment can be completed
01 – Hospital / 011 – Psychiatric Facility [Institutions for Mental Diseases (IMDs) that are free standing or have independent organizational structure] / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Copy of Division of Mental Health and Addiction (DMHA) Private Mental Health Facility license or certification
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Copy of license from appropriate state
• Proof of Medicare participation or own state’s Medicaid program / • Can only be enrolled as a billing provider, cannot be a group with members
• DMHA certifies Indiana psychiatric hospitals
• C&T sent directly to EDS from ISDH
01 – Hospital / 013 – Long Term Acute Care (LTAC)
Stand alone specialty that cannot be active with 010, 011, or 012. LTACs are enrolled hospitals that have been approved as an LTAC by Medicare and have received a rate letter from the rate setting contractor
Note, this specialty only effective on or after 11/01/03. / • Not a new enrollment, this is a change to the specialty of an enrolled hospital (Billing Update).
• Copy of ISDH license complying with IC 16-21 for LTAC
• Copy of Centers for Medicare and Medicaid Services (CMS) LTAC approval letter / Not eligible for enrollment / • Can only be enrolled as a billing provider, cannot be a group with members
• Meyers and Stauffer determines qualification during the course of each hospital rate-setting period; a rate letter is sent directly to EDS.
02 – Ambulatory Surgical Center / 020 – Ambulatory Surgical Center (ASC) / • Billing Provider Application
• Provider Agreement
• Copy of license from the ISDH
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Copy of license from appropriate state
• Proof of Medicare participation or own state’s Medicaid program / • Can only be enrolled as a billing provider, cannot be a group with members
• C&T sent directly to EDS from ISDH is required for Indiana providers before enrollment can be completed
03 – Extended Care Facilities / 030 – Nursing Facility
031 – Intermediate Care Facility for the Mentally Retarded (ICF/MR)*
032 – Pediatric Nursing Facility
033 – Residential Care Facility*
* Specialties that must submit a signed provider agreement annually to recertify. / • Billing Provider Application
• Provider Agreement*
• Federal W-9 tax form
• ISDH certification with recertification annually**
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Can only be enrolled as a billing provider, cannot be a group with members
• **C&T sent directly to EDS from ISDH is required for Indiana providers before enrollment can be completed
• Specialty 031 and 033 must recertify annually by submitting a new signed provider agreement.
03 – Extended Care Facilities / 034 – Psychiatric Residential Treatment Facilities (PRTF) / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Indiana Family and Social Services Administration (IFSSA) residential child care license for a private, secure care facility 470 IAC 3-13
• Copy of JCAHO or COA accreditation credentials
• Attestation letter for facility compliance / ICHP does not enroll these OOS providers / • Can only be enrolled as a billing provider, cannot be a group with members
• Credential accreditation must be for a residential behavioral facility.
04 – Rehabilitation Facilities / 040 – Rehabilitation Facility / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Copy of ISDH license
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Can only be enrolled as a billing provider, cannot be a group with members
• C&T sent directly to EDS from ISDH is required for Indiana Providers before enrollment can be completed
05 – Home Health Agencies / 050 – Home Health Agency / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Can only be enrolled as a billing provider, cannot be a group with members
• C&T sent directly to EDS from ISDH is required for Indiana Providers before enrollment can be completed
• Additional service locations are identified as branch locations
06 – Hospice / 060 – Hospice / • Billing Provider Application
• Provider Agreement
• CMS Medicare certification letter for each service location
• Federal W-9 tax form
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Can only be enrolled as a billing provider, cannot be a group with members
• C&T sent directly to EDS from ISDH is required for Indiana Providers before enrollment can be completed
• Additional service locations are identified as satellite sites
08 – Clinics / 080 – Federally Qualified Health Center (FQHC) / • Billing Provider Application
• Provider Agreement
• FQHC approval letter from the Department of Health and Human Services for each location
• Federal W-9 tax form
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Must be enrolled as a group with members linked
• Requires rate information furnished by the state’s rate setting contractor
08 – Clinics / 081 – Rural Health Clinic (RHC) / • Billing Provider Application
• Provider Agreement
• CMS Medicare approval letter for each location
• Federal W-9 tax form
• Nurse practitioner on staff
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Must be enrolled as a group with members linked
• C&T sent directly to EDS from ISDH is required for Indiana Providers before enrollment can be completed
08 – Clinics / 082 – Medical Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Proof of Medicare participation or own state’s Medicaid program / Must be enrolled as a group with members linked
08 – Clinics / 083 – Family Planning Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Proof of Medicare participation or own state’s Medicaid program / Must be enrolled as a group with members linked
08 Clinics / 084 – Nurse Practitioner Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Proof of Medicare participation or own state’s Medicaid program / Must be enrolled as a group with members linked
08 – Clinics / 086 – Dental Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Proof of Medicare participation or own state’s Medicaid program / Must be enrolled as a group with members linked
08 – Clinics / 087 – Therapy Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Proof of Medicare participation or own state’s Medicaid program / Must be enrolled as a group with members linked
09 – Advanced Practice Nurse / 090 – Pediatric Nurse Practitioner
091 – Obstetric Nurse Practitioner
092 – Family Nurse Practitioner
093 – Nurse Practitioner (other)
094 – Certified Registered Nurse Anesthetist (CRNA)
095 – Certified Nurse Midwife / • Billing Provider Application
• Provider Agreement
• Copy of license from the Health Professions Bureau (HPB)
• Copy of the Nurse Practitioner (NP) certification from accredited NP certifying organization
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Copy of NP certification from accredited NP certifying org
• Proof of Medicare participation or own state’s Medicaid program / May be enrolled as a billing, a group with members, or a rendering provider linked to a group
11 – Mental Health Provider / 110 – Outpatient Mental Health Clinic / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Outpatient Mental Health Addendum
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / Must be enrolled as a group with members linked
11 – Mental Health Provider / 111 – Community Mental Health Center / • Billing Provider Application
• Provider Agreement
• Certification from IFSSA – Division of Mental Health
• Federal W-9 tax form
• Outpatient Mental Health Addendum
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / Must be enrolled as a group with members linked
11 – Mental Health Provider / 114 – Health Service Provider in Psychology (HSPP) / • Billing Provider Application
• Provider Agreement
• Copy of current license from HPB listing the HSPP endorsement
• Federal W-9 tax form / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Proof of Medicare participation or own state’s Medicaid program / May be enrolled as a billing, a group with members, or a rendering provider linked to a group
11 – Mental Health Provider / 118 – EPSDT RO (Residential Treatment Facilities)
Note: Provider will have unique rates dependent on license, these rates will be UCC rates loaded to specific service locations identified by license level. / • Billing Provider Application
• Provider Agreement
• Residential child care license
• Certification letter from the IFSSA
• Federal W-9 tax form
• Copy of Title IV-E rate letter or rate letter exemption
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Must be enrolled as a billing provider only
• Must be approved by IFSSA before submitting enrollment application
• Rate letter sent directly from Rate Setting Contractor to load UCC rate for H0037
11 – Mental Health Provider / 119 – EPSDT RO (Outpatient Treatment Centers) / • Billing Provider Application
• Provider Agreement
• Outpatient Mental Health Addendum
• Residential child care license
• Certification letter from the IFSSA
• Federal W-9 tax form
• CLIA certificate, if applicable / IHCP does not enroll these OOS providers / • Must be enrolled as a group with members linked
• Must be approved by IFSSA before submitting enrollment application
12 – School Corporation / 120 – School Corporation / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• Must be listed on the approved Indiana Department of Education’s school corporation list / IHCP does not enroll OOS school corporations / Billing provider only
13 – Public Health Agency / 130 – County Health Department / • Billing Provider Application
• Provider Agreement
• Federal W-9 tax form
• CLIA certificate, if applicable / IHCP does not enroll OOS public health agencies / Can be a billing or group provider
14 – Podiatrist / 140 – Podiatrist / • Billing Provider Application
• Provider Agreement
• Copy of license from HPB
• Federal W-9 tax form
• CLIA certificate, if applicable / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Proof of participation in own state’s Medicaid Program or Medicare participation. / May be enrolled as a billing, a group with members, or a rendering provider linked to a group
15 – Chiropractor / 150 – Chiropractor / • Billing Provider Application
• Provider Agreement
• Copy of license from the HPB
• Federal W-9 tax form / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Proof of Medicare participation or own state’s Medicaid program / May be enrolled as a billing, a group with members, or a rendering provider linked to a group
17 – Therapist / 170 – Physical Therapist
171 – Occupational Therapist
173 – Speech/Hearing Therapist / • Billing Provider Application
• Provider Agreement
• Copy of license from the HPB
• Federal W-9 tax form / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Proof of Medicare participation or own state’s Medicaid program / May be enrolled as a billing, a group with members, or a rendering provider linked to a group
18 – Optometrist / 180 – Optometrist / • Billing Provider Application
• Provider Agreement
• Copy of license from the HPB
• Federal W-9 tax form / Same as in–state requirements, except:
• Copy of license from the appropriate state
• Proof of participation in own state’s Medicaid program / • May be enrolled as a billing, a group with members, or a rendering provider linked to a group
• Optometry groups must be owned by optometrists (IC 25-1-9-5)
19 – Optician / 190 – Optician / • Billing Provider Application