Indiana Health Coverage Programs P R O V I D E R T Y P E A N D S P E C I A L T Y M A T R I X V E R S I O N 4. 0 A U G U S T 2 0 0 4 The following table lists provider type and specialty codes with the enrollment requirements and provider classification information Note: Items in italics are not required. 01 Hospital 010 Acute Care Specialty Codes 011 Psychiatric (distinct part or unit) 012 Rehabilitation (distinct part or unit) 01 Hospital 011 Psychiatric Facility [Institutions for Mental Diseases (IMDs) that are free standing or have independent organizational structure] 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. In State Copy of Indiana State Department of Health (ISDH) license Proof of Medicare participation Copy of Division of Mental Health and Addiction (DMHA) Private Mental Health Facility license or certification 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 Out-of-State (OOS) Copy of license from appropriate Proof of participation in own s Medicaid program Copy of license from appropriate own s Medicaid program Not eligible for enrollment Classifications and Certificate and Transmittal (C&T) sent directly to EDS from ISDH is required for Indiana before enrollment can be DMHA certifies Indiana psychiatric hospitals ISDH Meyers and Stauffer determines qualification during the course of each hospital rate-setting period; a rate letter is sent directly to EDS. EDS Page 1 of 13
Attachment A Type and Specialty Matrix August 2004 02 Ambulatory Surgical Center 03 Extended Care Facilities 03 Extended Care Facilities 04 Rehabilitation Facilities Specialty Codes 020 Ambulatory Surgical Center (ASC) 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. 034 Psychiatric Residential Treatment Facilities (PRTF) In State Copy of license from the ISDH * ISDH certification with recertification annually** 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 040 Rehabilitation Facility Copy of ISDH license Out-of-State (OOS) Copy of license from appropriate own s Medicaid program ICHP does not enroll these OOS Classifications and ISDH is required for Indiana before enrollment can be **C&T sent directly to EDS from ISDH is required for Indiana before enrollment can be Specialty 031 and 033 must recertify annually by submitting a new signed provider agreement. Credential accreditation must be for a residential behavioral facility. ISDH is required for Indiana s before enrollment can be EDS Page 2 of 13
Attachment A Type and Specialty Matrix August 2004 05 Home Health Agencies Specialty Codes In State 050 Home Health Agency 06 Hospice 060 Hospice CMS Medicare certification letter for each service location 08 Clinics 080 Federally Qualified Health Center (FQHC) FQHC approval letter from the Department of Health and Human Services for each location 08 Clinics 081 Rural Health Clinic (RHC) CMS Medicare approval letter for each location Nurse practitioner on staff 08 Clinics 082 Medical Clinic Out-of-State (OOS) own s Medicaid program Classifications and ISDH is required for Indiana s before enrollment can be Additional service locations are identified as branch locations ISDH is required for Indiana s before enrollment can be Additional service locations are identified as satellite sites linked Requires rate information furnished by the s rate setting contractor linked ISDH is required for Indiana s before enrollment can be linked EDS Page 3 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes In State 08 Clinics 083 Family Planning Clinic 08 Clinics 084 Nurse Practitioner Clinic 08 Clinics 086 Dental Clinic 08 Clinics 087 Therapy Clinic 09 Advanced Practice Nurse 11 Mental Health 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 Copy of license from the Health Professions Bureau (HPB) Copy of the Nurse Practitioner (NP) certification from accredited NP certifying organization 110 Outpatient Mental Health Clinic Outpatient Mental Health Addendum Out-of-State (OOS) own s Medicaid program own s Medicaid program own s Medicaid program own s Medicaid program Copy of NP certification from accredited NP certifying org own s Medicaid program Classifications and linked linked linked linked May be enrolled as a billing, a group with, or a rendering provider linked EDS Page 4 of 13
Attachment A Type and Specialty Matrix August 2004 11 Mental Health 11 Mental Health 11 Mental Health 11 Mental Health 12 School Corporation Specialty Codes In State 111 Community Mental Health Center Certification from IFSSA Division of Mental Health Outpatient Mental Health Addendum 114 Health Service in Psychology (HSPP) 118 EPSDT RO (Residential Treatment Facilities) Note: will have unique rates dependent on license, these rates will be UCC rates loaded to specific service locations identified by license level. 119 EPSDT RO (Outpatient Treatment Centers) Copy of current license from HPB listing the HSPP endorsement Residential child care license Certification letter from the IFSSA Copy of Title IV-E rate letter or rate letter exemption Outpatient Mental Health Addendum Residential child care license Certification letter from the IFSSA 120 School Corporation Must be listed on the approved Indiana Department of Education s school corporation list Out-of-State (OOS) own s Medicaid program IHCP does not enroll OOS school corporations Classifications and linked May be enrolled as a billing, a group with, or a rendering provider 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 linked Must be approved by IFSSA before submitting enrollment application Billing provider only EDS Page 5 of 13
Attachment A Type and Specialty Matrix August 2004 13 Public Health Agency Specialty Codes In State 130 County Health Department 14 Podiatrist 140 Podiatrist Copy of license from HPB 15 Chiropractor 150 Chiropractor Copy of license from the HPB 17 Therapist 170 Physical Therapist 171 Occupational Therapist 173 Speech/Hearing Therapist 18 Optometrist Copy of license from the HPB 180 Optometrist Copy of license from the HPB 19 Optician 190 Optician Copy of Retail Merchants certificate (s who have non-profit status are exempt from this requirement) 20 Audiologist 200 Audiologist Copy of license from the HPB Out-of-State (OOS) IHCP does not enroll OOS public health agencies Proof of participation in own s Medicaid Program or Medicare participation. own s Medicaid program own s Medicaid program Proof of participation in own s Medicaid program Proof of participation in own s Medicaid program Classifications and Can be a billing or group provider May be enrolled as a billing, a group with, or a rendering provider May be enrolled as a billing, a group with, or a rendering provider May be enrolled as a billing, a group with, or a rendering provider May be enrolled as a billing, a group with, or a rendering provider linked to a group Optometry groups must be owned by optometrists (IC 25-1-9-5) Can be enrolled as a billing provider or as a rendering provider linked only to an optometry group, cannot be a group with May be enrolled as a sole practitioner (billing), a group with, or a rendering provider EDS Page 6 of 13
Attachment A Type and Specialty Matrix August 2004 21 Case Manager *09 Advanced Practice Nurse with prescriptive authority 21 Case Manager *09 Advanced Practice Nurse with prescriptive authority 21 Case Manager 22 Hearing Aid Dealer Specialty Codes 210 Care Coordinator for Pregnant Women without nursing license *210 Care Coordinator for Pregnant Women with nursing license (to be used when NP has prescriptive authority) 211 HIV Case Manager without nursing license *211 HIV Case Manager with nursing license (to be used when NP has prescriptive authority) 213 Targeted Case Management (TCM) 214 TCM Elderly and Disabled In State Care Coordinator certificate from National Association of Social Workers (NASW) *Copy of NP certification *Copy of license from HPB HIV Care Coordinator certificate from MATAC *Copy of NP certification *Copy of license from HPB Targeted Case Management Addendum from the Bureau of Fiscal Services 220 Hearing Aid Dealer Copy of hearing aid dealer license from the HPB 24 Pharmacy 240 Pharmacy Copy of Indiana Pharmacy Permit Out-of-State (OOS) Copy of appropriate s Hearing Aid Dealer s License Copy of license or permit from the appropriate Classifications and May be enrolled as a sole practitioner (billing), a group with, or a rendering provider May be enrolled as a sole practitioner (billing), a group with, or a rendering provider Must have Certification from the ISDH, sent directly to EDS before enrollment can be May be enrolled as a sole practitioner (billing), a group with, or a rendering provider Certification from the Bureau of Fiscal Services sent directly to EDS before enrollment can be Can only be enrolled as a billing Can only be enrolled as a billing EDS Page 7 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes In State 25 DME 250 DME Medicare assignment letter if enrolled Copy of Retail Merchants certificate (s that have non-profit status are exempt from this requirement) 260 Ambulance Emergency Medical Services (EMS) commission certification 261 Air Ambulance EMS commission Air Ambulance certification 262 Bus Motor Carrier Services (MCS) certificate from the Indiana Department of Revenue Out-of-State (OOS) Proof of own s Medicaid participation, or Proof of Medicare participation Prior authorization (PA) for services required To bypass PA requirements, a business office must be staffed during regular business hours with telephone service in Indiana and qualify with the Indiana Secretary of State as a foreign corporation. Copy of appropriate s EMS commission certification Copy of appropriate s EMS commission certification Copy of appropriate s certification for buses MCS certificate showing inter authority if the provider crosses lines Classifications and Can only be enrolled as a billing Requires EMS recertification prior to license expiration date Requires EMS Air Ambulance recertification prior to license expiration date Requires MCS recertification prior to certificate expiration date EDS Page 8 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes 263 Taxi Taxis cannot transport outside of the jurisdiction designated by the city taxi licensing authority. To transport out of its jurisdiction, a taxi must be enrolled as a common carrier through the Motor Carrier Services division of the Indiana Department of Revenue. According to the Indiana Department of Revenue, to transport across county borders a taxi must be certified as a common carrier and to transport across lines, a taxi must have inter authority. 264 Common Carrier (For Profit Ambulatory) 265 Common Carrier (For Profit Non- Ambulatory) 264 Common Carrier (Not For Profit Ambulatory) 265 Common Carrier (Not For Profit Non-Ambulatory) In State Document showing operating authority from the local governing body (City Taxi or Livery license) Copy of Retail Merchants certificate (s that have non-profit status are exempt from this requirement) Copy of driver s licenses for all drivers Proof of insurance as indicated by local ordinances (if unspecified by local ordinance, a minimum of $25,000/$50,000 public livery insurance covering all vehicles used in the business) Copy of MCS certificate from the Indiana Department of Revenue Copy of Not For Profit Status letter from IRS Copy of driver s licenses for all drivers Proof of insurance ($500,000 combined single limit commercial automobile liability insurance is required) 266 Family Member Authorization letter from the local Office of Family and Children (contact a caseworker), see 405 IAC 5-4-3 Proof of insurance and copy of driver s license Out-of-State (OOS) Document showing taxi operating authority from the local governing body Copy of appropriate s certification for Common Carriers MCS certificate showing inter authority if the provider crosses lines Same as in requirements Copy of appropriate s certification for Common Carriers MCS certificate showing inter authority if the provider crosses lines Not applicable Classifications and Requires insurance recertification prior to insurance expiration date, and copy of updated local governing body authority (unless authority has no expiration date). A copy of your receipt for annual recertification is acceptable. Requires MCS recertification prior to certificate expiration date Requires insurance recertification prior to insurance expiration date Requires recertification prior to insurance expiration date EDS Page 9 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes 27 Dentist 271 General Dentistry 272 Oral Surgeon 273 Orthodontist 274 Pediatric Dentist 275 Periodontist 277 Prosthesis In State Copy of license from the HPB 27 Dentist 276 Mobile Dentist Copy of Mobile Dental license from HPB 28 Laboratory 29 Radiology 30 End- Stage Renal Disease (ESRD) Clinic 280 Independent Lab 281 Mobile Lab 290 Free-standing X-Ray Clinic 291 Mobile X-Ray Clinic CLIA certificate required Registration certificate Notice of compliance from the ISDH Operator certificates for all employee operators, except PET CT scanner operators PET and MRI services do not require certification or notice of compliance 300 ESRD Clinic ISDH certification Out-of-State (OOS) Proof of participation in own s Medicaid program due to Indiana mobile dental license requirements, unless licensed by the Indiana HPB Same as in- requirements Proof of participation in own s Medicaid program Same as in requirements except: Proof of participation in own s Medicaid program OOS mobile radiology that perform services in the of Indiana, must be certified in Indiana and possess a notice of compliance in Indiana. All operators must be certified in the of Indiana Classifications and May be enrolled as a sole practitioner (billing), a group with, or a rendering provider linked Can only be enrolled as a billing May be enrolled as billing (sole practitioner) or a group with (Type 31-Specialty 341) linked to the group ISDH is required before enrollment can be EDS Page 10 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes In State Out-of-State (OOS) Classifications and May be enrolled as a sole practitioner (billing), a group with, or a rendering provider s who intend to be a PMP with Hoosier Healthwise managed care must choose one of the following specialties as primary: 318 (General Practitioner), 316 (Family Practitioner), 344 (General Internist), 328 (Obstetrician/Gynecologist), or 345 (General Pediatrician) 31 Physician 310 Allergist 311 Anesthesiologist 312 Cardiologist A copy of license from the HPB EDS 313 Cardiovascular Surgeon own s Medicaid program 314 Dermatologist Copy of board certification for 315 Emergency Medicine Practitioner specialty requested, if applicable 316 Family Practitioner 317 Gastroenterologist 318 General Practitioner 319 General Surgeon 320 Geriatric Practitioner 321 Hand Surgeon 323 Neonatologist 324 Nephrologist 325 Neurological Surgeon 3 Neurologist 327 Nuclear Medicine Practitioner 328 Obstetrician/Gynecologist 329 Oncologist 330 Ophthalmologist 331 Orthopedic Surgeon 332 Otologist, Laryngologist, Rhinologist 333 Pathologist 334 Pediatric Surgeon 336 Physical Medicine and Rehabilitation 337 Plastic Surgeon 338 Proctologist 339 Psychiatrist 340 Pulmonary Disease Specialist 341 Radiologist 342 Thoracic Surgeon 343 Urologist 344 General Internist 345 General Pediatrician 346 Dispensing Physician Page 11 of 13
Attachment A Type and Specialty Matrix August 2004 31 Physician with subspecialty Specialty Codes 322 Internist (with subspecialty) 023 Adult Critical Care Medicine 024 Adolescent Medicine 335 Pediatrician (with subspecialty) 001 Adolescent Medicine 002 Diagnostic Lab Immunology 003 Developmental Pediatrics 004 Medical Toxicology 005 Neonatal-Perinatal Medicine 006 Pediatric Allergy 007 Pediatric Cardiology 008 Pediatric Critical Care Medicine 009 Pediatric Dermatology 010 Pediatric Emergency Medicine 011 Pediatric Endocrinology 012 Pediatric Gastroenterology 013 Pediatric Hematology- Oncology 014 Pediatric Infectious Diseases 015 Pediatric Nephrology 016 Pediatric Neurology 017 Pediatric Otolaryngology, Rhinology 018 Physical Medicine and Rehabilitation 019 Pediatric Pulmonology 020 Pediatric Rheumatology 021 Pediatric Sports and Fitness Medicine 022 Pediatric Urology In State A copy of license from the HPB Copy of board certification for specialty requested, if applicable Out-of-State (OOS) own s Medicaid program Classifications and May be enrolled as a sole practitioner (billing), or a group with. Cannot be a rendering provider; rendering must use specialties 344 (General Internist) or 345 (General Pediatrician). EDS Page 12 of 13
Attachment A Type and Specialty Matrix August 2004 Specialty Codes 32 Waiver 350 Aged and Disabled Waiver 351 Autism Waiver 352 ICF/MR Waiver 353 OBRA/DD Waiver 354 Medically Fragile Children s Waiver 356 Traumatic Brain Injury 357 Assisted Living Waiver 358 Adult Foster Care Waiver 359 DD Waiver 360 Support Services Waiver 361 SED Waiver In State Approved application from the IFSSA Bureau of Fiscal Services Waiver Unit Out-of-State (OOS) Same as in requirements Classifications and All waiver enrollments must be certified by the Bureau of Fiscal Services before IHCP enrollment can be May be enrolled as a sole practitioner (billing), a group with, or a rendering provider EDS Page 13 of 13