Provider Information

How To Become a Contracted Provider For In-Home Services
How To Become A Certified Medicaid Waiver Provider
Area 9's Monthly Billing Forms For CHOICE/SSBG
Other Forms From Area 9

How To Become a Contracted Provider For In-Home Services

To begin the process of becoming an Area 9 contracted provider, download the PDF file below and then complete four signed copies of the contract along with other pertinent documents, such as Certificate of Liability Insurance, noted on the bottom of the Fee For Service Agreement and return to us by mail. Please contact Director of In-House Services for further information by calling (765)966-1795 or (800)458-9345.

The Area 9 contract consists of three parts: the Memorandum of Agreement, the Attachment A, and the Fee for Service Agreement, as well as other noted documents to process your contract. We also need a copy of the IU Provider Information/W-9 form. Click on each link below and print out a copy of each of these required documents.

Fiscal Year 2012-2013
(July 1, 2011 through June 30, 2013)
Memorandum of Agreement pdf
Attachment A pdf
Fee For Service Agreement* pdf
IU Provider Information/W-9 pdf
Fiscal Year 2013-2014
(July 1, 2013 through June 30, 2014)
Memorandum of Agreement pdf
Attachment A pdf
Fee For Service Agreement* pdf
IU Provider Information/W-9 pdf

*Note on the Fee For Service Agreement that you also need to submit a packet (one copy only) containing the following:

  • Copy of license, if applicable
  • Copy of Medicaid Waiver Provider certification (all CHOICE providers must be certified as Indiana Medicaid Waiver Providers as of April 1, 2004)
  • Copy of most recent State Board of Health Review, if applicable
  • Copy of Certificate of Liability Insurance
  • Copy of provider's brochure
  • Board of Directors listing, including addresses (Title III, SSBG only)
  • Graphic representation of organizational structure (Title III, SSBG only)

How To Become A Certified Medicaid Waiver Provider

Indiana's Division of Aging has issued policies requiring all CHOICE providers to be Medicaid Waiver providers and vice versa.

The link below provides some information on setting up your billing status with EDS to facilitate payments.

http://www.indianamedicaid.com/ihcp/ProviderServices/enrollment_provider_
process.asp

Contact information for state provider enrollment services:
Linda Wolcott
Provider Relations
(317) 234-0373

Area 9's Monthly Billing Forms For In-Home Services

Invoice Summary Sheetpdf
Client Specific Service Form pdf
Claim Voucher pdf (updated March 2014)

Other Forms From Area 9

Community Services Claim Voucher pdf

CHOICE Incident Reporting Form

Online Incident Reporting Site for Medicaid Waiver