Service Medical

Indiana Health Coverage Programs

Prior Authorization Request Form

Traditional ADVANTAGE Traditional P: 800-***-**** F: 800-***-**** Hoosier Healthwise Anthem Hoosier Healthwise P: 866-***-**** F: 866-***-**** Anthem HHW – SFHN P: 800-***-**** F: 800-***-****

MDwise Hoosier Healthwise See www.mdwise.org

MHS Hoosier Healthwise P: 877-***-**** F: 866-***-**** Healthy Indiana Plan

Anthem HIP P: 866-***-**** F: 866-***-****

MDwise HIP See www.mdwise.org

MHS HIP P: 877-***-**** F: 866-***-****

Hoosier Care Connect

Anthem P: 866-***-**** F: 866-***-****

MDwise P: 844-***-**** F: 844-***-****

MHS P: 877-***-**** F: 800-***-****

Care Select ADVANTAGE and MDwise P: 800-***-**** F: 800-***-**** Please complete all appropriate fields.

Patient Information Requesting Provider Information Medicaid ID/RID#: Requesting Provider NPI#:

DOB: Tax ID#:

Patient Name: Service Location Code:

Address: Provider Name:

City/State/ZIP Code: Rendering Provider Information Patient/Guardian Phone: Rendering Provider NPI#:

PMP Name: Tax ID#:

PMP NPI: Name:

PMP Phone: Address:

Ordering, Prescribing, or Referring (OPR)

Provider Information

City/State/ZIP Code:

OPR Physician NPI#: Phone:

Medical Diagnosis

(Use of ICD Diagnostic Code Is Required)

Fax:

Dx1 Dx2 Dx3 Preparer’s Information

Please check the requested assignment category below: DME Inpatient Physical Therapy

Purchased Observation Speech Therapy

Rented Office Visit Transportation

Home Health Occupational Therapy Other

Hospice Outpatient

Name:

Phone:

Fax:

Dates of Service

Start Stop

Procedure/

Service Codes

Modifier(s) Requested Service Taxonomy POS Units Dollars Notes:

PLEASE NOTE: Your request MUST include medical documentation to be reviewed for medical necessity. Signature of Qualified Practitioner Date:

Check the box of

the plan in which

the member is

enrolled.

IHCP Prior Authorization Request Form

Version 3.1, April 2015

Page 1 of 1

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