Forms

Provider Forms

Provider forms are available in the following categories:

What's on this page

• Behavioral Health Forms
• Claims Forms
• Pharmacy Forms
• Care Management Forms
• Provider Enrollment Forms for Hoosier Healthwise
  and HIP
• Notification of Pregnancy
• Member Reassignment Form
• Vision Eligibility Request
• HEDIS Fax Back Form

Behavioral Health Forms

• Referral for Behavioral Health Services (PDF)
• Case Management/Disease Management Referral Form

Substance Use Disorder Forms:

• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form (PDF)  - This form must be used to request PA for inpatient and residential SUD treatment services, rather than using the standard universal PA request form.
• Initial Assessment Form for Substance Use Disorder Treatment Admission (PDF)  - This assessment form must be completed and submitted as an attachment to the SUD residential and inpatient treatment PA request form for initial admissions.
• Reassessment Form for Continued Substance Use Disorder Treatment (PDF)  - This assessment form must be completed and submitted for requests to extend authorization for residential and inpatient SUD treatment.

Claims Forms

MDwise has moved to Optum Clearinghouse. 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
• www.optum.com/eps
• Claim Adjustment Request Form (PDF)
• Claims Dispute Form (PDF)
• Readmission Dispute Form (PDF)
• Provider Refund Remittance Form (PDF)
  

Claims Inquiry

Providers can use myMDwise provider portal to quickly view their claims. New users will need to request an account.

Pharmacy Forms

Mail Order Pharmacy - Mail Order/Home Delivery Form for Hoosier Healthwise and HIP (PDF)

Pharmacy Appeals Coversheet - Pharmacy Appeals Coversheet for Hoosier Healthwise and HIP

Medication Request Forms for Hoosier Healthwise and HIP

• Antiviral Monoclonal Antibodies Form (PDF)
• Benzo-Opioid Duplicate Therapy PA Form (PDF)
• Bone Formation Stimulating Agents PA Form (PDF)
• Brand Medically Necessary PA Form (PDF)
• Buprenorphine-Opioid Concurrent PA Form (PDF)
• Cardiac Agents PA Form (PDF)
• Carisoprodol PA Form (PDF)
• Dificid PA Form (PDF)
• Early Refill PA Form (PDF)
• Growth Hormone Adult PA Form (PDF)
• Growth Hormone Children PA Form (PDF)
• Hetlioz PA Form (PDF)
• High Dollar Compounded Rx PA Form (PDF)
• Lucemyra PA Form (PDF)
• Mental Health Meds PA Form (PDF)
• Narcolepsy Agents PA Form (PDF)
• Nuedexta PA Form (PDF)
• Opioid MME Limit Exceed PA Form (PDF)
• PBM Call Center PA Form (PDF)
• PCSK9 and Select Lipotropics PA Form (PDF)
• Phosphodiesterase Inhibitors for COPD PA Form (PDF)
• Pulmonary Antihypertensives PA Form (PDF)
• Testosterones PA Form (PDF)
• Uterine Disorder Agents PA Form (PDF)
• Vaginal Antimicrobials PA Form (PDF)

Care Management

• Care Management/Disease Management/Case Management Referral  - Providers will need to login to the myMDwise provider portal to complete this form.
• Case Management/Disease Management Referral Form

Provider Enrollment Forms for Hoosier Healthwise and HIP

• W-9 Request for Taxpayer Identification Number (PDF)
• IHCP Provider Ownership and Managing Individual Maintenance Form (PDF)
• IHCP MCE Practitioner Enrollment Form (PDF)
• IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form (PDF)
  

Notification of Pregnancy

Notification of Pregnancy

OMPP implemented a program in July 2009 aimed at improving birth outcomes for pregnant Medicaid members.

• Notification of Pregnancy (NOP)
• NOP Quick Reference Guide (PDF)  - View frequently asked questions regarding reimbursement, billing, CPT codes, benefits and other information.
• Guide to completing the NOP (PDF)  - Step-by-step guide on how to complete the NOP through the Indiana Medicaid Provider Portal.

Member Reassignment Form

• Download: Provider Request for Member Reassignment (PDF)
• Primary Medical Provider (PMP) Change Request Form (English) (PDF) Primary Medical Provider (PMP) Change Request Form (Spanish) (PDF) Primary Medical Provider (PMP) Change Request Form (Burmese) (PDF)

Vision Eligibility Request Form

• Download: Vision Eligibility Request Form (PDF)

HEDIS Fax Back Form

• Download: HEDIS Fax Back Form (PDF)