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Get IN Prior Authorization Request Form

Indiana Health Coverage Programs Prior Authorization Request Form Traditional Hoosier Healthwise Check the box of the plan in which the member is enrolled. Healthy Indiana Plan Care Select Advantage Traditional Anthem Hoosier Healthwise Anthem HHW SFHN MDwise Hoosier Healthwise MHS Hoosier Healthwise Anthem HIP MDwise HIP MHS HIP Advantage Care Select MDwise Care Select P 800-269-5720 F 800-689-2759 P 866-408-7187 F 866-406-2803 P 800-291-4140 F 800-747-3693 See www. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity. .

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