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MDwise Franciscan St. Margaret Mercy and St. Anthony Hoosier Healthwise Provider Information Guide 2014 MDwise Franciscan St. Margaret Mercy & St. Anthony Health Hoosier Healthwise All members will have an ID card. The Hoosier Healthwise ID card is the standard, state issued card as seen below. Eligibility and Benefits Verification: Claims Inquiry: Phone: (317)630-2831 or (800)356-1204 http://www.mdwise.org and go to myMDwise login IHCP Website Phone: (800)738-6770 Claims Submission: MDwise Franciscan St. Margaret PO Box 501310 Indianapolis, IN 46250 Payer ID Emdeon 35199 Relay Health/McKesson 2235 MDwise Franciscan St. Anthony PO Box 503050 Indianapolis, IN 46250 Claim Disputes and Appeals: Franciscan St. Margaret & St. Anthony Health Plans or submit in writing to: MDwise Franciscan St. Margaret or St. Anthony Dispute P.O. Box 441423 Indianapolis, IN 46244-1423 Provider Directory: MDwise Provider Manual http://www.mdwise.org March 2014 | APP0169 (9/14) Member Services: Refer member questions to: MDwise Phone: (317)630-2831 or (800)356-1204 Medical Prior Authorization: Services requiring authorization are listed on the reverse side. Call or fax Authorization Request form to: Franciscan St. Margaret and St. Anthony Medical Management Phone: (800)291-4140 Fax: (800)747-3693 Authorization Request Form can be obtained by calling the number above or at http://www.mdwise.org Rx Formulary: Formulary and list of drugs available at www.indianapbm.com Catamaran Clinical/Technical Help Desk Phone: 1-(855) 577-6317 Transportation Assistance: Members can call (800)356-1204 Mental Health/Substance Abuse: MDwise Franciscan Saint Margaret / Saint Anthony SMM: PO Box 501310 / STA: PO Box 503050 Indianapolis, IN 46250 BH Provider Relations: (800)356-1204 or (317)630-2831 BH Prior Authorizations: 866-770-0208 or Fax: (800)747-3693 MDwise Franciscan St. Margaret Mercy and St. Anthony Hoosier Healthwise Provider Information Guide 2014 Services Requiring Prior Authorization 1. All Services / Visits furnished by Out-of-Network Physicians, Providers, Facilities and Suppliers 2. All Inpatient, Observation and Hospital Admissions: This includes but is not limited to Medical, Obstetrics, Surgical, and Rehabilitation *Contact Utilization Management @ 1.800.291- 4140 extension 4 for verification or questions 3. All Transfers Inpatient and / or outpatient services between acute-care facilities 4. All In-Network Specialist – Prior Authorization is Required 5. Air Transportation and Any Transportation over 50 miles or over state lines 6. Out Patient Services - includes but is not limited to: Laryngoplasty Audiological Surgeries and Procedures Implantable DME Hyperbaric Oxygen Therapy 7. Diagnostic Services – Neurospinal Stimulators / Replacements Dressing Changes Requiring Anesthesia Implants / Electrode Placement Any Lesion Removal includes but is not limited to: All All Genetic Testing PET Scans Sleep Studies Cardiac Catheterization Pediatric Services Requiring Anesthesia Ultrasounds * Guidelines can be found in the IHCP Manual Amniocentesis BSER with Anesthesia 8. All Transplant Evaluations and Procedures 9. All Endoscope / Gastroenterology Services 10. Pain Management Services- including injections (separate from surgical procedures) 11. Surgery Procedures – includes but is not limited to: Bariatric Experimental / Investigative Nerve Blocks Spinal Surgery Device (re) Placement Percutaneous Vertebroplasty Orchiopexy All T&A’s Gastric Neuostimulator Procedures March 2014 | APP0169 (9/14) Exploratory of the ear and / or eye Computer Assisted Surgery TMJ Surgery or Manipulation All Skin Grafts MDwise Franciscan St. Margaret Mercy and St. Anthony Hoosier Healthwise Provider Information Guide 2014 12. All Dermatology 13. Cosmetic Procedures – (all settings) includes but is not limited to: Gastroplasty Abdominoplasty Lipectomy Rhinoplasty Gastroplasty Lesion Removal (any Method) Ligation and Stripping of the Veins Reduction Mammoplasty Dermabrasion 14. Durable Medical Equipment – DME – includes but is not limited to: Orthotics / Prosthetics Electronic Breast Pumps Glasses after Cataract Surgery Implantable DME Enteral Supplies Wheelchairs and all Wheelchair Components – manual and motorized *For Expanded listing and Member Eligibility please refer to the IHCP Manual 15. Behavioral Health – includes but is not limited to: ECT All Inpatient Admissions TMS Neuropsychological Testing Complex Interactive Intensive Outpatient Therapy Out of Network Providers Psychological Testing Vargus Stimulation Partial Hospitalization *Effective 2/1/2014 MDwise no longer requires Prior Authorization for Outpatient Behavioral Health Services for Hoosier Healthwise and Health Indiana Plan (HIP) for the following: Individual Therapy: 90832, 90834, 90837 Family Therapy: 90846, 90847, 90849 Group Therapy: 90853 * Refer to the IHCP Manual for Authorization Guidelines and Benefits 16. Additional – includes but is not limited to: Radiation Oncology Infusion Clinic Hearing Aids Psychiatric Services – Delegated to CMCS PT/OT/ST Home Health Care Skilled Nursing Facility Out of Network Providers are Required to Obtain Prior Authorization for all Services 17. Non-Covered Services – Refer to the IHCP Manual for coverage and benefit limitations @ www.indianamedicaid.com March 2014 | APP0169 (9/14)
