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  • Mdwise Dme Auth Form

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DME/ORTHOTICS/PROSTHETICS PRIOR AUTHORIZATION REQUEST IF NOT COMPLETED IN FULL REQUEST WILL BE RETURNED Phone 888-961-3100 Fax 888-465-5581 Your request MUST include Physician s Order and Documentation of Medical Necessity Hx Previous Tx Consult evals Rehab Evals and Tests to be processed. MEDICAL EQUIPMENT REQUESTS Member Name Last First THIS BOX FOR MDwise Hoosier Alliance USE ONLY Middle Form Received / / DOB / / Ph Guardian if applies Case M.

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Contacts for Members Not Enrolled in a Health Plan: Traditional Medicaid (Not enrolled in a health plan)Member Services800-457-4584Pharmacy Services855-577-6317

The PA attachment allows a provider to document the clinical information used to determine whether or not the standards of medical necessity are met for the requested service(s).

Any health care provider (with the exception of radiologists, anesthesiologists, pathologists, hospitalists and laboratory services providers) who is not participating with CareSource must obtain prior authorization for all non- emergency services rendered to a CareSource member. services.

Call us at 1-877-822-7196 or in the Indianapolis area 317-822-7196. There are representatives that can help you.

If you have questions about IHCP provider enrollment, enrollment status or provider profile updates, call Customer Assistance at 800-457-4584 and select option 2, and then option 1 to check provider enrollment status or option 3 to update provider enrollment information.

Our Medicaid Plans MDwise works with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs.

With the myMDwise app, you can manage your health care on the go. Or go to your phone's app store. Then search for "MDwise" and download.

PA requests may be submitted to Gainwell online via the IHCP Provider Healthcare Portal; by mail or fax, using the appropriate PA request form; or (in some cases) by telephone at 800-457-4584, option 7.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232