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
April 18, 2024
MDwise had an error in a small number of member ID cards. If you find the information on the patient’s MDwise ID card is not correct, please have the member outreach to MDwise Customer Service at 1-800-356-1204 so a new ID card can be issued to the member.
Thank you and MDwise appreciates your partnership.
April 6, 2024
Change Healthcare Outage
MDwise is aware of the recent cybersecurity incident with Change Healthcare and although MDwise is not directly impacted we understand the barriers this may cause our provider partners.
For those providers impacted by the Change Healthcare outage and in need of accommodations with claims, appeals or authorizations, please notify MDwise no later than 5/6/2024. Notifications must be in writing and can be sent directly to your dedicated provider representative. You can find your dedicated provider representative’s contact information here.
MDwise will work collaboratively with each provider who notifies us on needed accommodations to:
- Waive timely filing for dates of service 12/1/2023 until 90 days following the cyber attack’s resolution.
- Waive timelines for claim adjustment requests received after 2/21/2024 until 60 days following the cyber attack’s resolution.
- Waive timelines for disputes and appeals received after 2/21/2024 until 90 days following the cyber attack’s resolution.
- Waive authorization requirements for medically necessary services after 2/21/2024 until 90 days follow the cyber attack’s resolution.
Providers do always have the option to drop claims to paper and submit them to MDwise at:
MDwise
P.O. Box 1575
Flint, MI 48501
MDwise is committed to working with providers that are impacted by the Change Healthcare cybersecurity incident and will work with our provider partners to resolve their issues as quickly as possible.
December 14, 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 January 1, 2024, the following medications have been added to the medical claim prior authorization (PA) list:
- Briumvi (ublituximab-xiiy)
- Cutaquig (immune globulin)
- Elahere (mirvetuximab soravtansine-gynx)
- Imjudo (tremelimumab-actl)
- Lunsumio (mosunetuzumab-axgb)
- Panzyga (immune globulin)
- Rezzayo (rezafungin)
- Riabni (rituximab-arrx, biosimilar)
- Ruxience (rituximab-pvvr, biosimilar)
- Tecvayli (teclistamab-cqyv)
- Truxima (rituximab-abbs, biosimilar)
- Tzield (teplizumab-mzwv)
- Zynyz (retifanlimab-dlwr)
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: (888) 465-5581
Fax MDwise Healthy Indiana Plan (HIP) Excel: (866) 613-1642
Email: padept@mdwise.org
Portal https://mdwisepp.zeomega.com/cms/ProviderPortal/Controller/providerLogin
As of January 1, 2024, claims for the following hyaluronate products will only be reimbursed under the pharmacy benefit with prior authorization (PA) required:
- Durolane
- Eufelxxa
- Gel-One
- Gelsyn-3
- GenVisc 850
- Hyalgan
- Hymovis
- Monovisc
- Orthovisc
- Supartz
- Synvisc/ Synvisc-One
- Triluron
- Trivisc
- VISCO-3
All pharmacy PA requests should be submitted to the MDwise Pharmacy Benefit Manager (PBM), MedImpact. Prior Authorization requests can be submitted via fax to (858) 790-7100.
To see the entire HCPCS Code List, visit the Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP effective 1/1/2024 on the MDwise website.
December 13, 2023
The Indiana Health Coverage Programs (IHCP) has announced the coverage of FDA-approved weight loss medications [Wegovy® (semaglutide) and Saxenda® (liraglutide)] for eligible Medicaid members under the age of 21 through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.
Medical necessity determinations will be made for eligible members on a case-by-case basis using peer-reviewed literature. Although covered medications will be made available to members via the pharmacy benefit, prior authorization (PA) requests should be submitted according to the medical benefit process as follows. Appropriate requests should include a diagnosis of morbid obesity with comorbid conditions and documentation of nutritional counseling and/or weight-loss programs and any pharmacological agents or interventions that have been used by the member. All medical PA requests should be submitted using the Indiana Health Coverage Programs (IHCP) Universal Prior Authorization Form. Requests are to be submitted using the generic codes J3490, J3590, or C9399 with the name of the requested medication clearly specified. Prior Authorization requests may be submitted via fax, email, or via our Authorization Portal.
Fax MDwise Hoosier Healthwise (HHW) Excel: (888) 465-5581
Fax MDwise Healthy Indiana Plan (HIP) Excel: (866) 613-1642
Email: padept@mdwise.org
Portal https://mdwisepp.zeomega.com/cms/ProviderPortal/Controller/providerLogin
Upon authorization, the prescriber may submit a prescription through the normal pharmacy ordering process. Although the PA is to be requested through the medical benefit process, a prescription will need to be written for the member to pick up the medication from an in-network pharmacy. Reassessments of medical necessity for continued authorization will occur every 6 months and should follow the same process outlined above.
For more information, please refer to IHCP bulletin BT2023148. If you have any questions about this announcement, please call the MDwise Provider Customer Service Unit at (833) 654-9192.
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