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Indiana Health Coverage Programs Prior Authorization ...

IHCP Prior Authorization Request Form Version , May 2021 Page 1 of 1 Indiana Health Coverage Programs Prior Authorization Request Form Fee-for-Service Gainwell Technologies P: 1-800-457-4584, option 7 F: 1-800-689-2759 Hoosier Healthwise Anthem Hoosier Healthwise P: 1-866-408-6132 F: 1-866-406-2803 CareSource Hoosier Healthwise P: 1-844-607-2831 F: 1-844-432-8924 MDwise Hoosier Healthwise P: 1-888-961-3100 F: 1-888-465-5581 MHS Hoosier Healthwise P: 1-877-647-4848 F: 1-866-912-4245 Healthy Indiana Plan (HIP) Anthem HIP P: 1-844-533-1995 F: 1-866-406-2803 CareSource HIP P: 1-844-607-2831 F: 1-844-432-8924 MDwise HIP P: 1-888-961-3100 F: 1-866-613-1642 MHS HIP P: 1-877-647-4848 F: 1-866-912-4245 Hoosier Care Connect Anthem Hoosier Care Connect P: 1-844-284-1798 F: 1-866-406-2803 MHS Hoosier Care Connect P: 1-877-647-4848 F: 1-866-912-4245 UnitedHealthcare P: 1-877-610-9785 F: 1-844-897-6514 Please complete all appropriate fields.

IHCP Prior Authorization Request Form Version 6.2, May 2021 Page 1 of 1 Indiana Health Coverage Programs Prior Authorization Request Form Fee-for-Service Gainwell Technologies P: 1-800-457-4584, option 7 F: 1-800-689-2759

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