Indiana Health Coverage Programs Prior Authorization Request Form
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1Indiana Health Coverage Programs
Prior Authorization Request Form
Traditional
ADVANTAGE Traditional
P: 800-269-5720
F: 800-689-2759
Hoosier Healthwise
Anthem Hoosier Healthwise
P: 866-408-7187
F: 866-406-2803
Check the box of
Anthem HHW – SFHN
P: 800-291-4140
F: 800-747-3693
the plan in which
MDwise Hoosier Healthwise
See
MHS Hoosier Healthwise
P: 877-647-4848
F: 866-912-4245
the member is
Anthem HIP
P: 866-398-1922
F: 866-406-2803
enrolled.
Healthy Indiana Plan
MDwise HIP
See
MHS HIP
P: 877-647-4848
F: 866-912-4245
Anthem
P: 866-408-6132
F: 866-408-7087
Hoosier Care Connect
MDwise
P: 844-293-6309
F: 844-407-6454
MHS
P: 877-647-4848
F: 800-912-4245
Care Select
ADVANTAGE and MDwise
P: 800-784-3981
F: 800-689-2759
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
1831263110
Patient/Guardian Phone:
Rendering Provider NPI#:
52-2280045
PMP Name:
Tax ID#:
PMP NPI:
Name:
Tobii Dynavox
PMP Phone:
Address:
2100 Wharton St. Ste 400
Ordering, Prescribing, or Referring (OPR)
City/State/ZIP Code:
Pittsburgh, PA 15203
Provider Information
OPR Physician NPI#:
Phone:
Medical Diagnosis
1-866-336-2737
Fax:
(Use of ICD Diagnostic Code Is Required)
Preparer’s Information
Dx1
Dx2
Dx3
Name:
Please check the requested assignment category below:
DME
Inpatient
Physical Therapy
Phone:
Purchased
Observation
Speech Therapy
Rented
Office Visit
Transportation
Fax:
Home Health
Occupational Therapy
Other
Hospice
Outpatient
Dates of Service
Procedure/
Modifier(s)
Requested Service
Taxonomy
POS
Units
Dollars
Start
Stop
Service Codes
Notes:
PLEASE NOTE: Your request MUST include medical documentation to be reviewed for medical necessity.
Signature of Qualified Practitioner
Date:
Page 1 of 1
IHCP Prior Authorization Request Form
Version 3.0, April 2015
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Parent category: Medical