Get Ihcp Waiver Billing Provider Enrollment And Profile Maintenance ...

Filling out the IHCP Waiver Billing Provider Enrollment and Profile Maintenance form can seem daunting, but with careful guidance, it can be a straightforward process. This guide will provide step-by-step instructions to ensure you correctly complete each section of the form.

Follow the steps to successfully fill out the IHCP Waiver Billing Provider Enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in an interactive PDF editor, which allows you to enter information directly from your computer screen.
2. Begin with the 'General Instructions' section. Familiarize yourself with the purpose of the packet, ensuring that you meet the required eligibility criteria before proceeding.
3. Complete 'Schedule A – Type of Request' by selecting the purpose of your submission, such as New Enrollment or Change of Ownership. This helps to categorize your request correctly.
4. Fill out 'Schedule A – Provider Information' by providing your National Provider Identifier (NPI), Taxpayer Identification Number (TIN), and indicate if you are a current or previous IHCP provider.
5. Proceed to 'Contact Information' to include the name, phone number, and email address of a contact person who can answer questions about the submission.
6. In 'Service Location Name and Address', enter the physical address where services are provided, matching it with your business name on the Federal W-9 form.
7. Fill out the 'Legal Name and Home Office Address' section, ensuring that the name and address correspond with the information assigned to your provider through tax documents.
8. Complete the 'Mailing Name and Address' section. This section can use a P.O. Box if preferred, as it is meant for correspondence.
9. For the 'Pay-To Name and Address' section, accurately detail where payment should be sent, ensuring the details align with billing procedures.
10. Include information regarding provider specialty and licensure by entering the License Number, Effective Date, and Expiration Date, as well as submitting any required documentation.
11. After filling in all applicable sections and ensuring supporting documentation is prepared, perform a final review using the quality checklist provided in the instructions.
12. Once complete, save the form, print it for mailing, and send it along with all required addenda and supporting documentation to the designated mailing address.

Start filling out your IHCP Waiver Billing Provider Enrollment and Profile Maintenance form online today!