Get (mce) Provider Enrollment Form - Indiana Medicaid

Filling out the (MCE) Provider Enrollment Form for Indiana Medicaid can seem daunting, but with clear guidance, you can complete it efficiently. This guide will walk you through each section and field of the form to ensure you provide all necessary information accurately.

Follow the steps to successfully complete the provider enrollment form:

1. Click ‘Get Form’ button to acquire the enrollment form and open it for editing.
2. Begin by selecting the program(s) for which you are enrolling, such as Healthy Indiana Plan (HIP), Hoosier Healthwise (HHW), or Care Select. Ensure to check the appropriate box that corresponds to your choice.
3. Fill in your practitioner data, including your CAQH number, name, degree, social security number, and date of birth. Be sure to capture all relevant identifiers, such as your National Provider Identifier (NPI) and any licenses.
4. Indicate your practice type and primary specialty. Specify if you are enrolling as an individual, group, or other entities, and provide secondary specialties if applicable.
5. Complete the section on hospital privileges, indicating whether you have delivery privileges if relevant. List any relationships or privileges you may have with hospitals.
6. Provide your primary practice information, including practice group name, service location address, and contact information. Make sure to check if your office is handicap accessible.
7. Fill out pay-to information by entering billing details such as billing address and contact information. This is crucial for ensuring correct payment processes.
8. If you have additional practice locations, list them in the designated section. Include similar details as requested for the primary practice.
9. Review and complete the attestation and authorization section. This part is crucial as it grants permission for credentialing entities to access your information. Ensure you read and understand your rights regarding the credentialing process.
10. Once all sections are completed, save your changes. You may choose to download, print, or share the completed form as needed.

Start your enrollment process by completing the provider enrollment form online today!