MDwise
Prior Authorization

Prior Authorization

MDwise Medicaid Prior Authorization Process

For pharmacy prior authorization forms, please visit our pharmacy forms.

Resources

• Portal Instructions
• Appendix A SPC Code Set
• Prior Authorization Reference Guide for Hoosier Healthwise and Healthy Indiana Plan
• Prior Authorization Appeal Request Form
• Universal Prior Authorization Form
• Residential/Inpatient Substance Use Disorder Treatment Prior Authorization Request Form

Prior Authorization Lists

• The Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP effective 10/1/24
• The Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP effective 10/1/23
• The Medical Prior Authorization and Exclusion Lists for Hoosier Healthwise and HIP effective 1/1/23
• Searchable Behavioral Health Services Prior Authorization and Exclusions Lists

Contact

PA Inquiry Phone Number

MDwise Excel Hoosier Healthwise (HHW):  888-961-3100
MDwise Excel Healthy Indiana Plan (HIP):  888-961-3100

PA Fax Submission

HHW: 888-465-5581
HIP Fax for Inpatient: 866-613-1631
HIP Fax for Outpatient: 866-613-1642

Email: padept@mdwise.org

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