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


Provider Forms

Provider forms are available in the following categories:

Behavioral Health Forms

Substance Use Disorder Forms:

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.

Claims Inquiry

Providers can use myMDwise provider portal to quickly view the status of 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

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

Medication Request Forms for Hoosier Healthwise and HIP

Care Management

Provider Enrollment Forms for Hoosier Healthwise and HIP

Notification of Pregnancy

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

Member Reassignment Form

Vision Eligibility Request Form

HEDIS Fax Back Form