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

November 18, 2020

There is a new Readmission Dispute form on our website. This is not to take the place of the Claims Dispute form for regular disputes. Please fill out the form completely as this will assist us with getting your dispute reviewed in a timely manner. The Readmission Dispute and the Claims Dispute form are located on the same page of our website at MDwise.org/for-providers/forms/claims. Your readmission dispute will be returned if you don't fill out the correct form. Please note there is a new email address to submit your Readmission Dispute.

The new email address is:

We will continue to receive Readmission Disputes you have already submitted to the old email address, but the new address is effective immediately.

October 23, 2020

MDwise appreciates the efforts of our PMPs to see our members, especially those included in our P4V measures. The W34 measure is no longer a measure for HEDIS and will be updated on all MDwise documents for 2021. MDwise will continue to payout the W34 measure according to the P4V program flyer through the end of 2020. We encourage providers to strive for the continued growth of preventive visits for children of all ages.

October 8, 2020

Since January 1, 2019, SoutheastTrans (“SET”) has served as the transportation services broker for MDwise for both the Hoosier Healthwise and HIP programs.  Effective October 31, 2020 MDwise will be transitioning the transportation services for MDwise members from SET to LogistiCare Solutions, LLC (“LogistiCare”).  Beginning October 31, 2020, MDwise members will no longer be utilizing SET services and will be utilizing LogistiCare.

Our goal is to make this transition of transportation brokers as seamless as possible for our members.  Members will continue to call the same MDwise customer service phone number to schedule their transportation appointments.  For appointments before 10/31/2020, members will be routed directly to SET.  For appointments on or after 10/31/2020, members will be routed to LogistiCare.

MDwise, SET and LogistiCare are committed to making this transition smooth for our members. If you have any questions, please reach out to your Provider Relations representative or call the Provider Customer Service Unit 1-800-356-1204.

September 30, 2020

As of the date of this posting, MDwise will no longer require prior authorization on the following imaging CPT codes:

72125, 72126, 72127, 74150, 74160, 74170, 70450, 70460, 70470, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72128, 72129, 72130, 72192, 72193, 72194, 74174, 74175, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 70336, 70540, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70556, 70557, 70558, 70559, 71555, 72195, 72196, 72197, 74181, 74182, 74183, 78071, 78072, 76390

Please note, imaging services provided in an out of network setting will require prior authorization. 

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

 August 25, 2020 

Effective 10/1/ 2020, all claims submitted to MDwise will be subject to Optum CES. CES is designed to automatically check each claim, on a pre-payment basis, for errors, omissions and questionable coding relationships by testing the data against industry rules, regulations and policies governing health care claims. CES will also detect coding errors, including but not limited to: errors relating to unbundling, incidental procedures, modifier appropriateness, diagnoses and duplicate claims.

Sources used by Optum CES for edits include, but are not limited to, the following:
  • National Correct Coding Initiative (NCCI) edits, including Medically Unlikely Edits (MUEs) Federal Register (the Daily Journal of the US Government that contains agency rules, proposed rules and public notices)
  • Medicare publications
  • Local and National Coverage Determinations (LCDs/NCDs) Outpatient Code Editor (OCE)
  • Medicare Code Editor (MCE)

What do you need to do?
Since many other carriers with whom you work already use Optum CES, we do not anticipate this implementation will disrupt how you work with MDwise. CES will replace our legacy edits and automatically review and catch errors, omissions and questionable coding. The end result will be streamlined claims, reduced reimbursement errors and improved payment integrity. All edits are transparent, and you will be able to look up specific claims and see both the edits and the sourced citations.

Claims will be reviewed through CES and if a claim is denied, it will show on your payment file or EOP. 

August 17, 2020

MDwise is aware that a number of faxes were rejected from the evening of 08/7/2020 to 11:30am on 8/10/2020. This includes faxes submitted to our Prior Authorization fax number(s). 

This error was due to a systems hardware failure and MDwise has corrected the issue. Please re-submit any fax that was submitted during this downtime with the original fax confirmation and MDwise will honor the original fax submission timeline.  If you have any questions or concerns, please reach out to the Provider Customer Service Unit at 1-833-654-9192.  

  June 30, 2020  

MDwise is aware that recently a number of clearinghouse rejections were sent incorrectly on or after 06/22/2020. The rejection message states, “Acknowledgement/Returned as unprocessable claim-The claim/encounter has been rejected has not been entered into the adjudication system”. 

This error is due to a recent system upgrade, and MDwise is working with our clearinghouse to correct it.  If you received this rejection in error, you do not need to resubmit the claim(s). The claims were received and will be processed.

If you have any questions or concerns, please reach out to the Provider Customer Service Unit at 1-833-654-9192.

April 24, 2020

MDwise is committed to providing high quality, cost-effective health care to our members. By establishing our Physician Pay for Value (P4V) Program, MDwise strives for 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. Learn about the P4V program here.

April 22, 2020

The 2020 Hoosier Healthwise and HIP PA and Exclusion lists are now available on the MDwise website. Five additions were made to the “MDwise Medications Requiring Prior Authorization Under the Medical Benefit” list. Codes J2507, J9042, J9022, J7332 now require prior authorization effective May 1, 2020. You can find the PA list here.

April 8, 2020

IHCP temporarily removes prior authorization for certain DME or HME supplies and services. MDwise will follow the guidance in their bulletin. Click here to see the IHCP Bulletin that covers the details.

March 20, 2020

MDwise is dedicated to keeping members and providers educated about COVID-19. FSSA issued a new bulletin for COVID-19, please take a look and stay tuned for any further updates.

March 19, 2020

MDwise will follow the below IHCP guidance:
The Indiana Health Coverage Programs (IHCP) will cover COVID-19 diagnostic testing without co-pays for IHCP members. Effective April 1, 2020, the IHCP will cover the following new Healthcare Common Procedure Coding System (HCPCS) codes. Coverage applies retroactively to claims with dates of service (DOS) on or after February 4, 2020.
  • U0001 – CDC 2019 novel coronavirus (2019-ncov) real-time RT-PCR diagnostic panel
  • U0002 – non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)

February 27, 2020

Effective April 15, 2020, MDwise will begin requiring the billing provider NPI, taxonomy and corresponding ZIP code+4 on all claims.

For the CMS 1500 form:
1.Box 24J (bottom): Rendering provider NPI (If applicable- may be the same as the billing NPI)
2.Box 33a: Billing provider NPI
3.Box 33b: Billing provider taxonomy

For the UB-04 form:
1.Box 1: Billing provider address and zip code+4
2.Box 56: Billing provider NPI
3.Box 81ccA: Billing provider taxonomy
Claims submitted after April 15, 2020 without the required NPI, taxonomy or zip code+4 in the appropriate box will be rejected.

For questions regarding this announcement, please contact the Claims department at 1-800-356-1204.

 December 30, 2019 

As of 02/01/20, MDwise will require prior authorization on non-routine maternity inpatient deliveries. Codes on the Maternity Code Exemption List are exempt from the prior authorization requirement.

 December 27, 2019 

Effective January 1, 2020, the Indiana Health Coverage Programs (IHCP) reimbursement for administering Vaccines for Children (VFC) vaccine will increase to $15 per dose. Providers will continue to bill the appropriate procedure code (CPT codes 90471-90474) with the SL modifier. For dates of service (DOS) on or after January 1, 2020, the VFC administration fee will be a maximum of $15 (payment is made at whichever is lower - $15 or the submitted charge).

Click here to see the IHCP Bulletin that covers the details.

December 4, 2019

We have added new MDwiseREWARDS! Members can now spend their points on a gym membership reimbursement and earn points by going to the gym.

For more information about Hoosier Healthwise MDwiseREWARDS, click here.

For more information about Healthy Indiana Plan (HIP) MDwiseREWARDS, click here.

  November 13, 2019  

Click here to view our updated 2019 HEDIS poster!

        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.

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:


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.
  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
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.

View archived news and announcements

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Preferred drug list (PDL) for Hoosier Healthwise

Preferred drug list (PDL) for HIP Plans


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