Step by Step Instructions

MDwise utilizes the IHCP MCE Practitioner Enrollment Form and IHCP MCE Hospital/Ancillary Provider Enrollment Form to enroll providers.

Step 1: Select the applicable form based on your provider type and specialty. Detailed instructions are provided to assist you with completing the forms.

IHCP MCE Practitioner Enrollment Form
IHCP MCE Hospital/Ancillary Provider Enrollment Form

To be considered for full enrollment, you must complete and submit the applicable form and supporting documents.

Options to obtain and/or submit the forms to MDwise:
Online: MProvider Connect (preferred)
Email: prenrollment@mdwise.org
Fax: 317-822-7310
Mail: MDwise Provider Enrollment, PO Box 441423, Indianapolis, IN 46244
To receive a paper enrollment form: Contact PR Enrollment at 317-822-7300 and press 1 for Provider Enrollment.

The processes within the Provider Network Participation consists of credentialing, contracting, and enrollment. For reference, MDwise utilizes IHCP standard definitions for the following processes. (Refer to Definitions)

Step 2: In addition to completing the IHCP MCE Enrollment Forms, please also review MDwise Primary Medical Provider Participation Requirements and Supporting Participation document requirements (below) which lists the additional required documentation as applicable.

Practitioner Participation Document Requirements

IHCP MCE Practitioner Enrollment Form
**Collaborative/Supervisory Agreement (required if applicable)
**Required for Advanced Practice Nurse (Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife), and Physician Assistant
CAQH Proview Online Application (If not currently enrolled)
MDwise requires the CAQH number be submitted on the IHCP MCE Practitioner Enrollment Form to initiate the credentialing process.
Please ensure the following requirements are addressed in your CAQH Proview Online Application (CAQH Application):
- All current licenses and an active license to practice in Indiana must be detailed in the “Professional ID” section of the CAQH Application
- (Page 35 of User Guide)
- Details of your current DEA or CDS certificate, as applicable, must be entered for each state where services are provided in the “Professional ID” section of the CAQH Application (Page 35 of the User Guide), and a copy uploaded in the “Uploading Documents” section of the CAQH Application
- Education/Training details must be completed as appropriate to specialty(ies) (Page 37 of the User Guide)
- All current, Indiana-based hospital affiliations must be detailed in the Hospital Affiliations section (Page 84 of the User Guide)
- Current Professional Liability Insurance (Malpractice Insurance Coverage) details must be entered in the “Professional Liability Insurance” section of the CAQH Application (Page 102 of the User Guide)
- Most recent five-years’ work history, in month/year format (employment gaps greater than 6 months explained), must be detailed in the “Employment Information” section of the CAQH Application (Page 117 of the User Guide)
- Provide a narrative explanation to any question answered as “Yes” in the “Disclosure” section of the CAQH Application (Page 124 of the User Guide)
- Select in the “Authorize” section of the online application the option that reads: “All health care organizations who indicate I am an affiliated provider or am in the process of becoming an affiliated provider.” Otherwise, you may choose us individually by clicking the second option and then selecting MDwise in the table below the choice. If MDwise cannot retrieve your application, this could delay approval. All details for completing this section of the CAQH application may be found on Page 125 of the CAQH Proview Provider User Guide.
- Ensure attestation to the completeness and accuracy of the CAQH application in the “Review and Attest” section that follows (Page 127 of the CAQH Proview Provider User Guide) within 120 days prior to submission of participation request to MDwise. Otherwise, your attestation may have expired upon credentialing and this could delay your approval.
Form W-9 (required if applicable)
(required to be signed within the last 12 months)
Disclosure Ownership and Interest Form (required for brand new contracts)
Attestation must be signed no more than 365 calendar days prior to application submission.

Hospital/Ancillary Participation Document Requirements

IHCP MCE Hospital/Ancillary Provider Enrollment Form
Form W-9 (required if applicable)
(required to be signed within the last 12 months)
State License
CMS site evaluation ‒ If state site survey is not available
Indiana Department of Health Accreditation Certificate with site survey
Copy of Medicare certification letter (Universal Form)
Copy of Medicaid certification letter
Liability coverage face sheet
Clinical Laboratory Improvement Amendments (CLIA) Certificate
(required if applicable)
Drug Enforcement Agency (DEA) Number
(required if applicable)
Disclosure Ownership and Interest Form (required for brand new contacts)

Step 3: Provider Network Participation Request Forms and all required documentation must be submitted together either to MDwise Provider Enrollment via MProvider Connect or by email or fax. Providers also have the option of submitting paper request via mail to: MDwise Provider Enrollment P.O. Box 441423, Indianapolis, IN 46244.

Step 4: The submitter will receive an automated acknowledgement and ticket number within five (5) business days of submission. The submitted documents are reviewed by the MDwise Provider Relations Enrollment Team for completion. (Refer to Definitions).

Step 5: Once all required documents have been received and complete, credentialing will begin and a contract/agreement will be sent to provider for review and signing. Once the contract/Agreement is signed, all pages must be returned to the MDwise Provider Relations Enrollment Team for processing.

NOTE: Credentialing must occur before a contract is accepted and signed by MDwise.

Step 6: After credentialing approval, where applicable, and after all systems have been updated, the provider will receive an executed MDwise Contract/Agreement and MDwise Network Participation Welcome Letter with the effective date according to the MDwise Network Effective Date Policy. The Welcome Letter will be sent within five (5) business days of the network participation process completion. The completion date for the network participation process is defined as all components of the network participation process being completed.

All Network Participation enrollment statuses can be checked directly in MProvider Connect. Providers can also by call 317-822-7300 and press 1.

MDwise Step by Step Instructions