important information

Medicaid eligibility review is underway for many MDwise members. Encourage patients to update their info with FSSA so they don’t lose their health coverage!

Info for patients

MDwise
For Providers

For 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.

News and Announcements

October 27, 2023

The recently updated HCPCS Code List (previously referred to as the Medical Prior Authorization and Exclusion List) for Hoosier Healthwise and HIP is now available on the MDwise website.

As of October 1, 2023, the following medications have been added to the prior authorization (PA) list:

  • Aduhelm (aducanumab-avwa)
  • Amvuttra (vutrisiran)
  • Enjaymo (sutimlimab-jome)
  • Fyarro (sirolimus protein-bound particles)
  • Kimmtrak (tebentafusp-tebn)
  • Leqembi (lecanemab-irmb)
  • Leqvio (inclisiran)
  • Nexviazyme (avalglucosidase alfa-ngpt)
  • Opdualag (nivolumab and relatlimab-rmbw)
  • Releuko (filgrastim-ayow)
  • Rolvedon (eflapegrastim-xnst)
  • Ryplazim (plasminogen, human-tvmh)
  • Saphnelo (anifrolumab-fnia)
  • Skyrizi (risankizumab-rzaa)
  • Spevigo (spesolimab-sbzo)
  • Tezspire (tezepelumab-ekko)
  • Tivdak (tisotumab vedotin-tftv)
  • Vyvgart (efgartigimod alfa-fcab)
  • Xenpozyme (olipudase alfa-rpcp)
  • Zynlonta (loncastuximab tesirine-lpyl)

All medical PA requests should be submitted using the Indiana Health Coverage Programs (IHCP) Universal Prior Authorization Form. Prior Authorization requests can be submitted via fax, email, or via our Authorization Portal.

Fax MDwise Hoosier Healthwise (HHW) Excel: 1-888-465-5581
Fax MDwise Healthy Indiana Plan (HIP) Excel: 1-866-613-1642
Email: padept@mdwise.org
Portal https://mdwisepp.zeomega.com/cms/ProviderPortal/Controller/providerLogin

To see the entire HCPCS Code List, visit the Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP effective 10/1/23 on the MDwise website.

June 2, 2023

Please be advised that the Indiana Health Coverage Programs (IHCP) is transitioning to a Statewide Uniform Preferred Drug List (SUPDL) for the Fee-For-Service (FFS) and managed care entities (MCEs). Beginning July 5, 2023, all MCEs will adopt the FFS preferred drug list (PDL), maintaining the same preferred and nonpreferred drug status, clinical criteria requirements, and format for prior authorization (PA) submission as the FFS program.

The SUPDL will include products in the drug classes listed on the FFS PDL. Patients utilizing nonpreferred products will need to be transitioned to preferred products within 90 days of the July 5, 2023, implementation date. If you feel it is medically necessary for your patient(s) to remain on a nonpreferred product, you will need to submit a prior authorization (PA) request.

PA requests for MDwise Healthy Indiana Plan (HIP) or Hoosier Healthwise enrollees should be sent to the MDwise Pharmacy Benefit Manager (PBM), MedImpact. You may contact the MedImpact PA Department by phone at (800) 788-2949, or PA requests may be faxed to (858) 790-7100.

We appreciate your efforts to ensure our IHCP members maintain access to their medications through the SUPDL transition and thereafter by selecting products on the SUPDL whenever possible. Thank you for the work you do caring for our members.

If you have any questions about the SUPDL as it pertains to MDwise Healthy Indiana Plan (HIP) and Hoosier Healthwise members, please call the MDwise Customer Contact Center toll-free at (800) 356-1204.

The Indiana Family & Social Services Administration (FSSA) has also provided list of frequently asked questions on the SUPDL.

February 1, 2023

As of February 1, 2023, MDwise will only cover blood glucose testing supplies, including those for a Continuous Glucose Monitor (CGM), through a contracted network pharmacy. In order for your patients to receive CGM supplies, you will need to write a prescription. The MDwise participating network pharmacy of your patients’ choice will then submit a claim to the pharmacy benefit. For those patients receiving CGM supplies from a non-pharmacy provider previously, an authorization for them to continue receiving CGM supplies from a non-pharmacy provider is effective through April 30, 2023. Non-pharmacy providers include home medical and durable medical equipment (DME) suppliers.

The affected CGM systems are:

  • Abbott Freestyle Libre
  • Dexcom
  • Medtronic Guardian Connect and Guardian Sensor
  • Senseonics Eversense

In addition, Indiana Medicaid has made updates to the Preferred Diabetes Supplies List (PDSL), including CGM systems. Beginning January 1, 2023, Dexcom G6 is the preferred CGM system. Any patient currently using a non-preferred CGM system will be required to change to Dexcom G6 no later than April 30, 2023. All new requests for non-preferred CGM systems and supplies will require prior authorization beginning February 1, 2023. Prior authorization requests may be faxed to the MDwise Pharmacy Benefit Manager, MedImpact, at 1-858-790-7100.

For more information about the PDSL, please refer to IHCP bulletin BT2022119. If you have any questions about this letter, please call the MDwise Provider Customer Service Unit at 1-833-654-9192.

December 29, 2022 Update

We regularly review paid claims for payment accuracy and compliance with CMS regulations, policies, contractual requirements and utilization standards. In the past, we contracted with HMS for clinical chart review services. Effective 2/1/2023, MDwise will transition these services to Cotiviti.

Cotiviti is a leading solutions and analytics company that provides payment accuracy services, including reviewing inpatient claims, to more than 100 commercial, Medicaid, and Medicare health plans and maintains a database of over 1.5 million providers. You can learn more about Cotiviti at www.Cotiviti.com

Here’s how the transition will work:

  • You will start receiving communication directly from Cotiviti for both medical record requests and completed reviews. Please review these letters carefully as the timeframes on the letters are specific and must be adhered to. 
  • Any reviews already in progress under the HMS name and all communication for those reviews will continue under the HMS name.
  • For the next few months during the transition, you may have both claim reviews already in progress under the HMS name and new claim reviews from Cotiviti.
  • As of 2/1/2023 you will no longer receive new requests for medical records under the HMS name, and Cotiviti will make all new requests.

If you need additional information at any time, please contact MDwise Provider Relations at 317-822-7300 option 1 or your dedicated Provider Relations Representative. 

December 22, 2022 Update

MDwise identified a fee schedule issue that occurred in July which caused HIP claims to price inaccurately. This issue was identified 10/16/2022 and was resolved 11/19/2022, however HIP claims processed between 7/1/2022 - 11/18/2022 will need to be reprocessed.

MDwise is in the process of adjusting 320,000 claims that were paid outside the expected HIP reimbursement rate and targeting to have all these claims reprocessed by 3/31/2023. If you have HIP claims during this period that processed inaccurately, there is no further action needed from you.

August 10, 2022 Update

As a result of the national formula shortage and Abbott recall, the Indiana Women, Infants and Children (WIC) program has put flexibilities in place to protect infant nutrition and promote appropriate feeding.

Please urge patients, clients and caregivers that are having trouble finding formula to contact the Indiana Department of Health MCH MOMS Helpline at 1-844-MCH-MOMS for information. For WIC-specific questions, individuals can call the WIC toll-free information line at 1-800-522-0874. If you suspect medical neglect regarding improper infant feeding, please contact the Indiana Department of Child Services Child Abuse Hotline at 1-800-800-5556.

For more information, visit the Provider Guidance and Updated WIC Documentation Form.

June 16, 2022 Update

Healthy Indiana Plan (HIP) Outpatient Reimbursement for Hospital Assessment Fee (HAF) and non-HAF eligible facility locations

MDwise has received clarification from the Office of Medicaid Policy and Planning (OMPP) that the calculations for HIP outpatient claims should be as follows:

  • HAF Eligible Hospital Locations: 100% IHCP Outpatient Fee Schedule x HAF factor
  • HAF Eligible Hospital Locations: 100% IHCP Outpatient Fee Schedule x HAF factor
Dates of Service (DOS) on or after: Outpatient HAF Factor
08/01/2020-07-31/2021 3.5
08/01/2021-07/31/2022 3.6
08/01/2022- current 3.9

As a reminder, HAF eligible facility locations are identified by OMPP by the Indiana Medicaid Provider ID. Only services performed directly at those specific locations are eligible to receive the enhanced HAF rate. Providers are encouraged to refer to the IHCP Healthy Indiana Plan and Hospital Assessment Fee Provider Reference Modules for further guidance related to HIP and HAF reimbursement guidelines.

MDwise is in the process of adjusting 148,000 claims that were paid outside of OMPP guidance related to HIP outpatient reimbursement. Adjustment letters will be sent to providers regarding their affected claims which are expected to be reprocessed by July 30, 2022.

March 29, 2022 Update

The recently updated HCPCS Code List (previously referred to as the Medical Prior Authorization and Exclusion List) for Hoosier Healthwise and HIP is now available on the MDwise website.

As of April 1, 2022, the following medications will require prior authorization.

  • Blenrep (belantamab mafodotin-blmf)
  • Enhertu (fam-trastuzumab deruxtecan-nxki)
  • Erwinaze (asparaginase)
  • Jemperli (dostarlimab-gxly)
  • Margenza (margetuximab-cmkb)
  • Padcev (enfortumab vedotin-ejfv)
  • Polivy (polatuzumab vedotin-piiq)
  • Poteligeo (mogamulizumab-kpkc)
  • Rybrevant (amivantamab-vmjw)
  • Sarclisa (isatuximab-irfc)
  • Trodelvy (sacituzumab govitecan-hziy)
  • Ultomiris (ravulizumab-cwvz)
  • Vyepti (eptinezumab-jjmr)

As of April 1, 2022, MDwise will allow coverage of the following medications under either the medical benefit or the pharmacy benefit. Although coverage at the pharmacy will continue, providers now have the option to procure the medication and submit claims to MDwise under the medical benefit (“buy and bill”). Please note that these medications will require prior authorization (PA) before medical claims will be considered for payment. A medical benefit PA is required even if the patient already has an approved PA under the pharmacy benefit.

  • Asceniv (immune globulin)
  • Evenity (romosozumab-aqqg)
  • Ocrevus (ocrelizumab)
  • Probuphine (buprenorphine implant)
  • Remicade (infliximab)
  • Sublocade (buprenorphine injection)
  • Xembify (immune globulin)

All medical PA requests should be submitted using the Indiana Health Coverage Programs (IHCP) Universal Prior Authorization Form. Prior Authorization requests can be submitted via fax, email, or via our Authorization Portal.
Fax MDwise Hoosier Healthwise (HHW) Excel: 1-888-465-5581
Fax MDwise Healthy Indiana Plan (HIP) Excel: 1-866-613-1642
Email: padept@mdwise.org
Portal https://mdwisepp.zeomega.com/cms/ProviderPortal/Controller/providerLogin 

Cultural and Language Resources

MDwise supports the needs of our diverse members and helps providers deliver culturally and linguistically appropriate services. Here are some resources that can help providers with that effort.

Interpreter services are free for all MDwise Hoosier Healthwise, Healthy Indiana Plan and Medicare members.

In-person Interpreter Requests

A member or provider may ask for in-person interpretation services for an appointment by calling 1-800-356-1204. MDwise provides these services free to our members. Requests for in-person interpretation should be made at least three business days in advance. MDwise will do its best to provide in-person interpretation for requests made less than three business days in advance. 

Follow the steps below to complete a request.

This information is required:

  • Member name and ID number
  • Language required
  • Appointment date and time (estimated duration, if known)
  • Complete address and phone number of on-site appointment
  • Purpose of appointment
  • Member’s phone number
  • Interpreter gender preferred

MDwise will schedule the in-person interpretation. Follow up will be done within two business days to confirm.

Telephone Interpreter Services

During business hours only, members and providers have the option to use oral interpreter services by calling 1-800-356-1204. The member or provider would explain the need for an interpreter and the preferred language. MDwise will connect the call for oral interpretation for any covered service. MDwise does not require advanced notice for oral interpreter services during business hours.

Quick Contact Guide

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

Quick Contact Guide

Prior Authorization Reference Guide

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

Prior Authorization Reference Guide