Welcome Providers

Welcome to the MDwise network. We value your participation and hope to keep you informed by providing easily accessible resources and updates here. Information about MDwise guidelines, requirements and policies and procedures can be found in the provider manual.

 

MDwise Quick Contact Guides

View our comprehensive quick contact guide includes contact information for Hoosier Healthwise and Healthy Indiana Plan. 

View our comprehensive Prior Authorization Reference Guide that includes PA contact information for Hoosier Healthwise and Healthy Indiana Plan.

 

News and Announcements


        October 14, 2019     

 
Healthcare Effectiveness Data and Information Set (HEDIS) is the measurement tool used by health plans to evaluate their performance in terms of clinical quality including measuring well-child visits.  For HEDIS well-child measures, please note that documentation in the patient’s chart is required for evidence of health education and anticipatory guidance.  Handouts in the record alone do not count as documentation of health education or anticipatory guidance.     
 
Examples of anticipatory guidance include specific documentation in the chart about: 
 

  • Nutrition

  • Oral health

  • Immunizations explained

  • Infant care

  • Behavior and development

  • Parent-infant interaction

  • Injury/illness prevention

 
Examples of health education includes specific documentation in the chart about: 

  • Injury and illness prevention

  • Nutrition

  • Oral health

  • Mental health

  • Sexuality

  • Social competence

  • Substance use and abuse prevention

  • Responsibility

  • School or vocational achievements

  • Family

  • Community

Documentation that does not count as documentation of anticipatory guidance/health education for well-child measures:
 

  • Allergies, medications, or immunizations alone

  • “Appropriate for age” without mentioning the type of physical and mental development

  • “Well-developed/nourished/appearing”

  • “Neurological exam” or “Appropriately responsive” for development

  • Vital signs alone for the physical exam

  • Health education/anticipatory guidance related to medications or immunizations or the side effects  




August 29, 2019 

  
Premature Discharges and Readmissions

 
MDwise continues to work collaboratively with all our providers to adjudicate claims both timely and accurately.  As a part of that process, we perform routine pre and post payment audits.  Recently we identified some irregularities in the billing/payment of readmissions. 
 
We realize it is important to remind our hospital partners of our criteria for these services.
 
As a subcontractor of FSSA, MDwise follows state laws, regulations and IHCP guidelines, including the following: 
 
  • Indiana Administrative Code 405 IAC 1-10.5-3 says, “Readmissions for the same or related diagnosis within three (3) calendar days after discharge will be treated as the same admissions for payment purposes.  Readmissions that occur after 3 calendar days will be treated as separate stays for payment purposes but will be subject to medical review.”
 
  • The IHCP Provider Manual, Inpatient Hospital Services Module, says “Readmissions greater than three days following a previous hospital discharge are treated as separate stays for payment purposes, but are subject to medical review.  If it is determined that a discharge is premature, payment made as a result of the discharge or readmission may be subject to recoupment.”
 
  • The Hospital Inpatient Services Module of OMPP’s Medical Policy Manual, says: “Readmissions are subject to medical review to determine if the previous discharge was premature.  Reviews are conducted based on statistical data sets for readmissions.  If the discharge was premature and payment made, the readmission or discharge may be subject to recoupment.  For payment purposes, readmissions within three days after discharge will be treated as the same admission, while readmissions after three days will be treated as separate stays but are subject to medical review.”

 
MDwise is reviewing readmissions and conducting medical reviews.  Readmissions within 3 days deny without any review.  Medical reviews will be completed for readmissions more than 3 days after discharge.
 
  1. Inpatient readmissions within three days following a previous hospital admission for any facility with the same or related diagnosis, should be billed on one claim (see Inpatient Hospital Services).
  2. Inpatient readmissions within 4-14 days following a previous hospital admission will deny for medical review. 
 
Providers who receive this denial and feel it is erroneous should do the following:
  1. Complete the 1st Level Readmission Dispute Form located at https://www.mdwise.org/for-providers/forms/claims.
  2. Collect the medical records for the inpatient readmission.
  3. Submit the completed form and supporting medical records to MDwiseclaims@mclaren.org or mail to:

MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501
Attn: 1st Level Readmission Disputes
 
Providers MUST submit the 1st Level Readmission Dispute Form and supporting medical records for the dispute to be processed.
 
MDwise will send an acknowledgement letter within 10 calendar days of receipt and will send a decision letter to the informal dispute within 30 calendar days.
 
If you have questions regarding the 1st Level Readmission Dispute process, please contact MDwise at 1-833-654-9192.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HHW-HIPP0625 (7/19)
 



August 5, 2019


Effective September 1, 2019, the 2017-2018 Valence Claims Portal will be retired (mdwportal.valence.care). Claim information for 2017-2018 claims can be accessed on the myMDwise portal at:

https://www.mdwise.org/for-providers/mymdwise-provider-portal

Payment Listings will not be available on the myMDwise portal. Please refer to your Clearinghouse, or paper copy.
 
For questions regarding this announcement or contracting, please call Provider Relations at 317-822-7300 ext. 5800
 



June 10, 2019


MDwise sent a list of claims to the state for encounter/shadow claim payments. The state returned part of this list stating that the provider either was not enrolled with the TIN, Group NPI, LPI billed, or was not actively enrolled under the TIN, NPI, LPI combo on the date of service. The state reviewed these claims and determined that based on how the claim was billed, this payment was made in error. Please verify with the state that your billing information submitted on the claim is correct. For directions on reconsideration by MDwise, please click here.



April 15, 2019


Effective June 1st, 2019, the Prior Authorization guide has been updated with additional Radiology codes. Please review our prior authorization guide for these code updates. These codes will require authorization effective June 1st, 2019 for all contracted and non-contracted providers.

For questions or concerns, please call 1-800-356-1204.



April 15, 2019


Effective June 1, 2019, all claims (non CMCS*), regardless of dates of service, must be sent to the address or electronic payer ID listed below. 
 

Paper Claims (Hoosier Healthwise and Healthy Indiana Plan):

MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501

 

Electronic Submission:

Hoosier Healthwise Payer ID: 3519M
Healthy Indiana Plan Payer ID: 3135M

 

Claims with dates of service January 1, 2017 to December 31, 2018 that are eligible for 365 timely filing are included in this change. Any claim that is not sent to the address or correct payer ID above will not be received by MDwise for processing. 
 

For questions regarding this announcement or contracting, please call Provider Relations at 317-822-7300 ext. 5800

*Hoosier Healthwise claims for St. Catherine, Select Health Network, and St. Vincent for DOS prior to 1/1/19 will continue to be processed by CMCS (payer ID 35199) 




February 12, 2019 

 

PA Criteria for Concomitant Opioid and Benzodiazepine Drug Therapies effective March 5, 2019


Recent updates to Opioid Analgesic and Benzodiazepine/Sedative Hypnotic Prior Authorization (PA) Criteria were approved by the Drug Utilization Review (DUR) Board at its August 17, 2018, meeting. The criteria changes will be effective for opioid analgesic and benzodiazepine PA requests submitted on or after March 5, 2019.

These updates are the result of the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) warnings about the risks of concomitant use of opioids, benzodiazepines, and central nervous system (CNS) depressants. These risks include “profound sedation, respiratory depression, coma, and/or death.” Prescribers are advised to “limit prescribing opioid pain medicines with benzodiazepines or other CNS depressants only to patients for whom alternative treatment options are inadequate.” Prescribing should be limited to the lowest doses and shortest durations necessary as the risk of drug overdose death was shown to increase in a dose-response fashion.1, 2, 3
 
Benzodiazepines are usually found in treatment guidelines for anxiety disorders as third-line therapy and are recommended for short-term use for anxiety situations that cannot be adequately treated with antidepressant therapy.4 “De-prescribing” and taper of benzodiazepine medications in patients who have been taking them for more than 4 weeks can be achieved by decreasing the dose of the benzodiazepine by 10% to 25% every 2 to 3 weeks over an 8 to 12 week time period.5
 
In an effort to limit these risks for members with newly prescribed concomitant therapy, changes have been made to PA criteria as follows:
  • For members with concurrent claims for a benzodiazepine and an opioid, exceeding a 7-day supply, dose, or quantity limit, the prescriber must provide:
 
  • Documentation of diagnoses demonstrating the medical necessity of both drugs
  • Documentation of alternative therapies attempted
  • An attestation confirming Indiana Scheduled Prescription Electronic Collection and Tracking (INSPECT) reviews, member education of the serious risks of concomitant therapy, and member and provider acceptance of serious risks of concomitant therapy
  • Documentation demonstrating the medical necessity of carisoprodol-containing medications combined with opioid and benzodiazepine concurrent therapies (if applicable)
 
  • In addition, please note the following:
 
  • A specific PA form to gather the above information for concomitant opioid and benzodiazepine drug therapies will be required for all PA reviews. The PA form is located here:  https://www.mdwise.org/for-providers/forms/pharmacy
  • PA criteria changes will not be applied to members concomitantly using benzodiazepines and opioid-based drugs for medication-assisted treatment of substance use disorder (SUD).6
  • To avoid the potentially serious effects of abrupt benzodiazepine discontinuation, these PA criteria changes will not be applied to members with preexisting concomitant use of opioids and benzodiazepines. However, applicable criteria for these members are under consideration for future implementation.
  • Members receiving high doses of opioids or opioid and benzodiazepine combinations should also be prescribed naloxone.2
 
Beginning March 5, 2019, PA requests for a MDwise member to receive concomitant opioid analgesic and benzodiazepine therapy may be faxed to MedImpact Healthcare Systems, Inc. at (858) 790-7100. If you have any questions regarding this process, please contact MedImpact’s Customer Service at (844) 336-2677.
 
References
  1. https://www.fda.gov/Drugs/DrugSafety/ucm518473.htm 
  2. https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf 
  3. https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids 
  4. Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch V et al. Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Can Fam Med 2018;64(5):339-51.
  5. Prushowski J, Rosielle PA, Pontiff L, Reitschuler-Cross E. Deprescribing and tapering benzodiazepines. J Palliat Med 2018;21 (7):1040-1.
  6. https://www.fda.gov/Drugs/DrugSafety/ucm575307.htm



January 10, 2019


Some pieces of mail were returned to providers in error that were originally sent to Eagan, Minnesota. MDwise is aware of the issue and it has now been resolved. Please resend any mail that was returned. Claims for dates of service prior to 1/1/19 are still to be sent to the addresses below. We are sorry for any inconvenience. 
 
MDwise HIP Claims
P.O. Box 211571
Eagan, MN 55121
 
Or
 
MDwise Hoosier Healthwise
P.O. Box 211572
Eagan, MN 55121
 
 



January 2, 2019


Effective January 1, 2019, claims must be submitted as follows:
 
Paper Claims (Hoosier Healthwise and Healthy Indiana Plan):
MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501
 
Electronic Submission via Optum Clearinghouse:
Hoosier Healthwise Payer ID:   3519M
Healthy Indiana Plan Payer ID: 3135M
 
This updated claim submission information is date of service driven and should not be used for dates of service prior to 1/1/2019. MDwise will move to Optum Clearinghouse for 2019. To receive electronic payments for 2019 dates of service, you will need to enroll with Optum at www.optum.com/eps.

Here you can find the updated Quick Contact Guide and Prior Authorization List.



November 15, 2018


MDwise is committed to providing high quality, cost-effective health care to our members. By establishing our P4V Program, MDwise will maintain a strong partnership with our PMPs, resulting in improved quality and access to health care services. The goal of the program is to improve access and health outcomes for all members. Effective January 1, 2019 the MDwise Pay for Outcomes (P4O) program will be replaced with the MDwise Pay for Value Program (P4V).

For more information on the P4V program, click here.



November 14, 2018


The 2019 Hoosier Healthwise and HIP PA and Exclusion lists are now available on the MDwise website. The lists are effective January 1, 2019. You can find the PA list here.



November 13, 2018


Effective January 1, 2019, MDwise will be restructuring its Delivery System model. The restructure will improve claim payment timeliness and accuracy, streamline and reduce administrative redundancy, and provide greater access for our members. This will include one standard authorization list, one point of contact for all authorization requests, and one claims submission address.

Effective January 1, 2019, claims must be submitted as follows:

Paper Claims (Hoosier Healthwise and Healthy Indiana Plan):
MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501
 
Electronic Submission via Optum Clearinghouse:
Hoosier Healthwise Payer ID:   3519M
Healthy Indiana Plan Payer ID: 3135M
 
This updated claim submission information is date of service driven and should not be used for dates of service prior to 1/1/2019. MDwise will move to Optum Clearinghouse for 2019. To receive electronic payments for 2019 dates of service, you will need to enroll with Optum at www.optum.com/eps.
 
For providers not currently contracted with MDwise Excel, you must obtain a MDwise Excel contract to continue providing services to MDwise members in 2019. If you are not currently contracted with MDwise Excel and would like to contract, please complete a Contract Inquiry Form and email to prenrollment@mdwise.org. For providers who do not wish to contract with MDwise Excel, a Non-Contracted Provider Set-up Form is required to ensure providers are loaded correctly for claims payment. Forms can be found here.

If you are currently contracted with MDwise Excel, no action is needed on your part for the 2019 transition.
For questions regarding this announcement or contracting, please call Provider Relations at 317.822.7300 ext. 5800.

We thank you for providing quality service to MDwise members and look forward to continuing our partnership in 2019!
 



November 7, 2018


Effective January 1, 2019, Southeastrans, Inc. will become the Non-Emergent Medical Transportation (NEMT) broker for MDwise.  The processes for scheduling transportation for members will not change.  Southeastrans will begin taking calls for member’s 2019 transportation trips on 12/17/18 and they can be reached by choosing ‘Transportation’ in the MDwise provider phone options. 



November 1, 2018


MDwise is moving to Optum Clearinghouse for 2019. To receive electronic payments for 2019 dates of service you need to enroll with Optum. If you are already enrolled with Optum for other payers, there is nothing else you need to do, Optum will add MDwise to your profile.
  • Providers will go through Optum to sign up
  • Can begin signing up 11/1/18 for 2019 dates of service
  • Optum: www.optum.com/eps



October 15, 2018


Effective December 1st, 2018, the MDwise authorization submission process will change for all 2019 dates of service. All authorization requests for 2019 dates of service must be sent to MDwise Excel as outlined below:

authorization_submission_process_change_chart-2-(2).jpg

All authorization requests for 2018 dates of service will continue to follow the current authorization submission process. A letter has been sent to our providers for more information and can be viewed here.

Please visit the Prior Authorization page for all current authorization lists. An updated 2019 authorization list will be posted to our website once available.

For questions or concerns, please contact Provider Relations at 317-822-7300 ext. 5800.



October 12, 2018


Effective January 1st, 2019, MDwise will be restructuring its Delivery System model. The restructure will improve claim payment timeliness and accuracy, streamline and reduce administrative redundancy, and provide greater access for our members. This will include one standard authorization list, one point of contact for all authorization requests, and one claims submission address.

If you are currently contracted with MDwise Excel, no action is needed on your part for the 2019 transition.

For providers not currently contracted with MDwise Excel, you must obtain a MDwise Excel contract to continue providing services to MDwise members in 2019. If you are not currently contracted with MDwise Excel and would like to contract, please complete a Contract Inquiry Form and email to prenrollment@mdwise.org. For providers who do not wish to contract with MDwise Excel, a Non-Contracted Provider Set-up Form is required to ensure providers are loaded correctly for claims payment.

For questions regarding this announcement or contracting, please call Provider Relations at 317.822.7300 ext. 5800.

We thank you for providing quality service to MDwise members and look forward to continuing our partnership in 2019!



August 1, 2018

 

Effective September 15th, 2018, the process for submitting a claim refund to MDwise will change. MDwise will now require a Provider Refund Form be submitted with the refund check. A sample Provider Refund Form is attached to this letter. Also, the submission address will change. Please send all claim refunds to:
 
MDwise, Inc.
P.O. Box 441423
Indianapolis, Indiana 46244-1423

 
Effective September 15th, 2018, any refund submitted without the Provider Refund Form completed and included, will be returned.   
 
To download the new required form, click here. For questions, please call 1-800-356-1204 or contact Provider Relations directly at 317-822-7300, extension 5800.




May 30, 2018

 

Dear Providers,

MDwise Excel is aware that recently there has been a large number of incorrect denials on DME claims. The denial rejection is DME5. This rejection on the EOB states DME/PROSTHETICS REVIEW. PA REQUIRED IF TOTAL CLAIM > $500. Many of these claims are less than the $500 and therefore denying incorrectly. MDwise is working with Evolent on the system configuration to correct this denial error. Once the system configuration is complete, we will be pulling a list of claims that need reprocessed. If you have any questions or concerns, please reach out to Michelle Phillips, mphillips@mdwise.org.




May 11, 2018

 


MDwise claims vendor, Evolent Health, transitioned to a new mailroom process and solution effective July 1, 2018. The new mailroom solution is supported by Smart Data Solutions. 

Claims or documents originally sent to Corpus Christi, TX will now go to Eagan, MN. Please refer to our website for our up to date Provider Contact Guide.

Addresses are below by program:

MDwise Healthy Indiana Plan
P.O. Box 211571
Eagan, MN 55121


MDwise Hoosier Healthwise **excludes those Delivery Systems who bill to CMCS**
P.O. Box 211572
Eagan, MN 55121 

MDwise Hoosier Care Connect
P.O. Box 211512
Eagan, MN 55121

MDwise Marketplace
P.O. Box 211473
Eagan, MN 55121


Evolent Health set up mail forwarding with USPS to ensure all mail received at the current mailing address is automatically directed to the new mailroom location.

We recognize that there have been issues with returned provider mail and we apologize for any inconvenience. Evolent Health has a dedicated courier at the prior Corpus Christi, TX mailroom location who will check for provider mail daily. The courier will overnight any mail to the new mailroom location.

If you have additional questions about claim and correspondence mail, please contact our Provider Relations Department at 317-822-7300 ext. 5800.

Sincerely,
MDwise Provider Relations




May 11, 2018

 

MDwise has a tool to assist providers in coordinating Physical and Behavioral Health services. PMPs can register to use our Member Health Profile tool and view services that their members have received over the past 12 months.
 
This tool will allow you to see services including:

  • Specialist visits
  • Behavioral health
  • ER visits
  • Pharmacy activity 

Note: Services related to Substance Use Disorder and Infectious disease are excluded.

To register, please use the training guide. If you have any questions, please reach out to your MDwise delivery system provider relations representative.
 
Sincerely,
Ty Sullivan, MD, MBA
Chief Medical Officer

 

 




April 11, 2018

 

MDwise would like to remind providers of changes in the coverage of medications under the medical and pharmacy benefits for the MDwise HIP & HHW plans. These changes will be effective on June 1, 2018.

Information concerning the scheduled changes is as follows:

 

A prescription will be needed for these medications to enable claims processing through one of the contracted network pharmacies (AllianceRx Walgreens Prime, IU Health Retail, or Eskenazi Retail Pharmacies).
 
Providers are encouraged to reach out to their assigned MDwise provider relations representative for any questions or concerns. Alternatively, you may contact MDwise customer service at 1-800-356-1204 or send an email inquiry to pharmacy@mdwise.org.

We thank you for partnering with MDwise to provide quality care for our members.
 
 




March 9, 2018

 

The MDwise relationship with former claims vendor DST is coming to a close. All issues for claims with dates of service prior to 1/1/17 are due no later than 3/15/18. Per the MDwise Provider Manual:
 

  • Contracted providers have 90 days from the date of service to file a claim.
  • Non-contracted providers have 365 days from the date of service to file a claim.
  • Disputes are accepted up to 60 days from the date of the EOB.

 
All claims issues with dates of service prior to 1/1/17 that are received outside of the 60-day dispute timeframe, will not be considered for further review.
 




February 7, 2018

 

MDwise would like to announce changes in the coverage of medications under the medical and pharmacy benefits for the MDwise HIP & HHW plans. These changes will be effective on April 1, 2018 and June 1, 2018.

Information concerning the scheduled changes is as follows:
 


A prescription will be needed for these medications to enable claims processing through one of the contracted network pharmacies (AllianceRx Walgreens Prime, IU Health Retail, or Eskenazi Retail Pharmacies).
 

Providers are encouraged to reach out to their assigned MDwise provider relations representative for any questions or concerns. Alternatively, you may contact MDwise customer service at 1-800-356-1204 or send an email inquiry to pharmacy@mdwise.org.

We thank you for partnering with MDwise to provide quality care for our members.


 




January 31, 2018

 

We are excited to announce that MDwise Excel Network has partnered with Edgepark Medical Supplies to be our preferred provider for MDwise Excel Hoosier Healthwise and MDwise Excel Healthy Indiana Plan, effective February 1, 2018.

Edgepark has been a trusted provider for many years, offering fast and easy ordering of medical supplies delivered to the home. Advantages of the Edgepark Program include:

  • Fast, free shipping
  • ContinuCare™ order reminder program via phone and e-mail to encourage member compliance with their prescription
  • Orders arrive to your patients in 1 - 2 business days, after order processing
  • Dedicated Care team to take patients’ orders by phone Monday – Friday, 7 a.m. – 8 p.m. CST, and Saturday, 8 a.m. – 2 p.m. CST or online anytime at edgepark.com.


We are confident that these advantages, coupled with Edgepark’s ability to provide us with utilization reporting insights, will help us work together to improve member outcomes.

If your office needs to order supplies for our members, please call Edgepark at 1-866-528-0347 or send them an order using the physician’s order form located at MDwise.org. You will soon be receiving Detailed Written Orders (DWO) from Edgepark. Please review, sign, and return to Edgepark timely.
 




January 3, 2018

 

McLaren Health Care has completed its previously announced acquisition of MDwise. The acquisition establishes McLaren's first operations outside the state of Michigan, and grows the system's health plan assets to jointly serve more than 620,000 individuals, making it one of the region's largest provider-sponsored plans. MDwise will continue to operate under its current brand.
 

About McLaren

McLaren Health Care, headquartered in Grand Blanc, Michigan, is a fully integrated health network committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 13 hospitals, ambulatory surgery centers, imaging centers, a 490-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 620,000 lives in Michigan and Indiana, home health and hospice providers, retail medical equipment showrooms, pharmacy services, and a wholly owned medical malpractice insurance company. McLaren operates Michigan's largest network of cancer centers and providers, anchored by the Barbara Ann Karmanos Cancer Institute, one of only 49 NCI-designated comprehensive centers in the U.S. McLaren has 26,000 employees and more than 52,500 network providers. Its operations are housed in more than 350 facilities serving the entire Lower Peninsula along with a portion of the Upper Peninsula. Learn more at www.mclaren.org.




November 2, 2017


MDwise has agreed to be purchased by McLaren Health Care, a large Michigan-based health system that provides Medicaid benefits to over 260,000 Michigan residents through McLaren Health Plan.
 
This will require no changes on your part. The current provider network will remain in place, and you can continue to follow current protocols, processes and procedures.
 
MDwise will keep the same name and continue to participate in Hoosier Healthwise and Healthy Indiana Plan.
 
In addition, the change will not have any effect on a Member’s benefits.



July 18, 2017


MDwise Marketplace will cease participation in the Federal Health Insurance Exchange in 2018. Effective January 1, 2018 we will no longer offer MDwise Marketplace plans. Click here to read the full statement.



April 5, 2017

MDwise transitioned our claims payment vendor to Valence Health on January 1, 2017. MDwise realizes that a change in claims payment vendor may disrupt claims payment to providers during implementation, and we apologize that some of you have experienced this. We are taking all measures necessary to ensure providers receive accurate payments. Click here to view the provider notice.



December 1, 2016

A new Electronic Funds Transfer (EFT) Agreement Form and Instructions for Hoosier Healthwise, HIP and MDwise Marketplace were posted to the MDwise website. They can be accessed below:

MDwise Claims Forms




November 21, 2016

Attention MDwise Medicaid Providers: The State and the three managed care entities (MCEs) that service Indiana Medicaid members (both HIP and HCC) have developed utilization management criteria to address the growing epidemic of opioid misuse, abuse, and addiction. Fee-For-Service Medicaid (OptumRx) has had these new opioid UM criteria in place for some weeks and the Indiana Medicaid MCEs are following suit in cooperation with the State.
 
This universal opioid UM initiative is being rolled out in a phased approach and will be complete by 1/1/2017. 

To read more information, view the full provider announcement.



November 17, 2016

Over the next several weeks, MDwise will be implementing some changes to our pharmacy network. These changes will affect both the traditional retail (non-specialty) as well as specialty pharmacy networks. 

Traditional (non-specialty) Retail Pharmacy network
  • CVS and Target will no longer be in the MDwise Pharmacy Network
  • All other IHCP-eligible pharmacies will remain in the network.
  • Walgreens will become the anchor for the MDwise pharmacy network

Click here to see the letter sent to MDwise providers with more information.



November 2, 2016


Download MDwise Marketplace announcement as PDF

MDwise would like to notify providers of changes in the claim submission for MDwise Marketplace Network claims. For your MDwise Marketplace claims with dates of services on or after January 1, 2017, please use the following addresses and submission information:
 

MDwise Marketplace Claims Address

PO Box 331428
Corpus Christi, TX 78463-1428
 

MDwise Marketplace Claims Inquires

1-855-417-5615
 

MDwise Marketplace Electronic Claims

Change Health/ Emdeon / WebMD Payer ID: 45627

Providers will need to make necessary changes to their billing software and processes to account for a change in payer for MDwise Marketplace claims.



November 2, 2016


Download Hoosier Healthwise, HIP and Hoosier Care Connect announcement as PDF

MDwise would like to notify providers of changes in the claim submission for MDwise Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect claims. For your MDwise claims with dates of services on or after January 1, 2017, please use the following addresses and submission information:

Impacted Hoosier Healthwise Delivery Systems Include:
  • MDwise Excel Network
  • MDwise IU Health
  • MDwise Total Health
  • MDwise Community Health Network
  • MDwise Eskenazi
 
All Healthy Indiana Plan and Hoosier Care Connect claims submissions should be sent to the claims address below regardless of Delivery System. 
 
Hoosier Healthwise
MDwise Hoosier Healthwise Claims
P.O. Box 331550
Corpus Christi, TX 78463-1550
Change Health/ Emdeon / WebMD Payer ID: 35191
Claims Inquiries: 1-800-356-1204
 
MDwise HHW Family Planning Claims
P.O. Box 331550
Corpus Christi, TX 78463-1550
Change Health/ Emdeon / WebMD Payer ID: 35191
Claims Inquiries: 1-800-356-1204
Healthy Indiana Plan
MDwise HIP Claims
P.O. Box 331609
Corpus Christi, TX 78463-1609
Change Health / Emdeon / WebMD Payer ID: 31354
Claims Inquiries: 1-800-356-1204
Hoosier Care Connect
MDwise Hoosier Care Connect Claims
P.O. Box 331538
Corpus Christi, TX 78463-1538
Change Health/Emdeon / WebMD Payer ID: 91313
Claims Inquiries: 1-800-356-1204

Providers will need to make necessary changes to their billing software and processes to account for a change in payer for MDwise Hoosier Healthwise claims.
 
Special Note: Claims payment for Hoosier Healthwise (Medical & Behavioral Health) for St. Vincent, St. Margaret Mercy, St. Catherine, and Select Health network remains unchanged. Please refer to the table above for Family Planning submission changes.

The MDwise quick contact guide posted at MDwise.org will be updated to reflect the above changes. 




June 23, 2016


Effective July 1, 2016: primary medical providers (PMP), specialists, behavioral health providers and hospitals in the Community Health Network are included in the MDwise provider network for MDwise Hoosier Healthwise and Healthy Indiana Plan. Please contact MDwise provider relations at 317-822-7300 ext. 5800 or by visiting MDwise.org/quickcontact.



March 1, 2016

 
Effective March 1, 2016: primary medical providers (PMP), specialists, behavioral health providers and hospitals in the Community Health Network are included in the MDwise provider network for Hoosier Care Connect and MDwise Marketplace members. Please contact MDwise provider relations at 317-822-7300 ext. 5800 or by visiting the Contact Us page.



April 13, 2016


An updated version of the 2016 Marketplace Prior Authorization list has been posted to the MDwise website. The new version contains an updated list of medical benefit drugs that require prior authorization.

The updated MDwise Marketplace PA list is located here.



January 26, 2016

Required Diagnosis Codes for Prior Authorization Requests

(Effective for dates of services on or after 10/1/2015)
 
To avoid delays in the processing of your authorizations, please ensure you are utilizing appropriate, ICD-10 diagnosis codes with your Prior Authorization request.
 
As a reminder, ICD-10 diagnosis codes often require four to seven characters to be considered a valid code.
 
The example below illustrates non-billable header codes that contain up to five characters. In this instance, the billable codes that contain six characters would be more appropriate.  
 
  • G43 – Migraine
    • G43.0 – Migraine without aura
      • G43.00 – Migraine without aura, not intractable
        • G43.001 – Migraine without aura, not intractable with status migrainosus
        • G43.009 – Migraine without aura, not intractable without status migrainosus

Please feel free to distribute this message to your coding and/or precertification teams. Additional prior authorization resources are available on the MDwise website.



January 20, 2016

Prior Authorization Required for Substitutable Brand Name Drugs

Beginning on January 21, 2016, MDwise Medicaid (Healthy Indiana Plan and Hoosier Care Connect) prescriptions for which the prescriber has indicated "Brand Medically Necessary" will follow a new procedure for review and determination. Pharmacies will no longer be able to submit the claim with a DAW code of 6 or 9 for these prescriptions. For consideration of 'Brand Medically Necessary' claims, the prescriber will be required to submit a prior authorization request. Those requests will be considered within 24 hours.

Prescribers should use the Brand Medically Necessary Form located on the Pharmacy Forms page of the MDwise website.



December 28, 2015

There are important changes coming to the Hoosier Care Connect program. Starting on January 1, 2016, Hoosier Care Connect members will begin paying copays.

For more information, see the letter sent to providers.



December 15, 2015


MDwise Corporate will be transitioning MDwise Excel Network Hoosier Healthwise prior authorization to our existing Prior Authorization system starting on January 1, 2016.

Since 11/16/15, new Hoosier Healthwise prior authorization requests for 2016 dates of service are already being inputted in the system. In an effort to ensure a seamless transition, steps have been taken to capture all authorizations which span from 2015 into 2016. However, if a provider receives a claim denial due to no authorization on file where services were part of an authorization which continued from 2015, please take the following steps to resolve the issue:
 
Follow the steps on the claim Explanation of Benefit to file a claim dispute.  Please refer to MDwise.org for the Claim Dispute form and process.

With your claim dispute, provide any documentation you may have of previously obtaining prior authorization for these dates of service. If you have any questions, please don’t hesitate to contact us at 800-356-1204.



November 17, 2015

Effective immediately, MDwise will reprocess claims for Healthy Indiana Plan (HIP), Presumptive Eligibility (PE) HIP and Hoosier Care Connect that were denied or rejected for reasons of eligibility or authorizations for dates of service (DOS) from February 1, 2015 through October 1, 2015. 

For more information see the
 letter sent to providers.

View archived news and announcements

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