Area 9's Notice of Privacy Practices

Information For Service Providers

How To Become a Contracted Provider For CHOICE/SSBG Clients

    To begin the process of becoming an Area 9 contracted provider, download the PDF file below and then complete and return to us by mail 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.  Please contact our billing department 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.  We must receive four signed copies of the Memorandum of Agreement, Attachment A, and Fee for Service Agreement as well as other noted documents to process your contract.  We only need one copy of the Provider Information/W-9 form.  Click on each link below and print out a copy of each of these required documents. 

    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) 

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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

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Area 9's Monthly Billing Forms For CHOICE/SSBG

    Invoice Summary Sheet

    CHOICE Client Specific Service Form

    SSBG Client Specific Service Form

    CHOICE Claim Voucher

    SSBG Claim Voucher

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Other Forms From Area 9

    Change in Service Delivery Form

    Community Services Claim Voucher

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* Files in PDF are accessible only through Adobe Acrobat Reader. Adobe Acrobat Reader can be downloaded free of charge from  Adobe's website.