IHCP Quick Reference Guide Contact Information

1 IHCP Quick Reference Guide Contact Information General Provider Customer Assistance Provider Enrollment Third-Party Liability (TPL) Fraud and Abuse Reporting Long-Term Care Rate- Information 1-800-457-4584 Setting IHCP Provider Enrollment IHCP TPL Office of Medicaid Policy & Planning for the (OMPP) Long-Term Care Audits Indiana Member Customer Assistance Box 7263 Box 7262. 1-800-457-4584 Indianapolis, IN 46207-7263 Indianapolis, IN 46207-7262 Program Integrity Myers and Stauffer Health 402 W. Washington St., Room W374. Coverage 1-800-457-4584 1-800-457-4584 Indianapolis, IN 46204-2739 1-800-877-6927. Member Applications Fax: (317) 571-8481. Programs 1-800-403-0864 Fax: 1-866-667-6579 (IHCP) IHCP Provider and Member Concerns Line TPL Casualty 1-800-457-4515. Fee-for-Service (FFS), Including Traditional Medicaid, Waiver, 590 Program, and Other FFS Coverage FFS FFS Prior Authorization (By FFS Electronic Transactions FFS Paper Claim Submission FFS Adjustment Forms Form Requests Information Mail, Phone, and Fax) Professional (Excluding Crossover) (No Refund Checks) Gainwell Forms Electronic Data Interchange Gainwell Adjustments Box 7263.

2 (Other than for For Medical, Dental, and Gainwell CMS-1500 Claims Substance Use Disorder (SUD) Box 7269 Box 7265 Indianapolis, IN 46207- Pharmacy and 1-800-457-4584 Indianapolis, IN 46207- 7263. Indianapolis, IN 46207-7269. Nonemergency Gainwell Prior Authorization 7265. Medical Box 7256 Paper Attachments for Electronic Professional Crossover Provider Inquiries and Transportation Indianapolis, IN 46207-7256 Claims Gainwell CMS-1500 Crossover Claims FFS Refunds Administrative Review [NEMT]) Gainwell Claim Attachments Box 7267 Gainwell Refunds Requests 1-800-457-4584, option 7 Box 7259 Indianapolis, IN 46207-7267 Box 2303, Dept. 130 Gainwell Written Fax: 1-800-689-2759 Indianapolis, IN 46207-7259 Institutional (Inpatient Hospital, Home Indianapolis, IN 46206- Correspondence Health, Outpatient Facility, Long-Term 2303 Provider Healthcare Portal IHCP Provider Healthcare Portal Care Including Crossover) Uncashed FFS Check (After logging in to the Portal, Gainwell UB-04 Claims click the Secure Returns IHCP Portal Help Desk Technical Box 7271 Correspondence link to Indianapolis, IN 46207-7271 Gainwell Finance Unit Assistance 950 N.)

3 Meridian St. submit a request). Dental Suite 1150. 1-800-457-4584 Gainwell Dental Claims Indianapolis, IN 46204- Box 7268. Indianapolis, IN 46207-7268 4288. FFS NEMT Member Trip Reservations Transportation Providers Facility Dispatch Special Services Request Administrative Claim Appeal Information Southeastrans Southeastrans Southeastrans (standing orders) Review Southeastrans Southeastrans Claim Appeals 1-855-325-7586 1-855-325-7611 1-888-822-6104 4751 Best Rd., Suite 300. 1-855-325-7588 Atlanta, GA 30337. FFS FFS Pharmacy Inquiries FFS Pharmacy Paper Claim FFS Pharmacy Claim FFS Pharmacy Administrative Review of FFS Pharmacy Refunds Pharmacy and Prior Authorization Filing Voids/ Claim Requests Courier Mail Information OptumRx Clinical and OptumRx Manual Claims Reversals OptumRx JP Morgan Chase Technical Help Desk Manual Claim Processing OptumRx Void/Reversals Manual Claim Processing OptumRx Claims LBX 26594.

4 Box 29044 Manual Claim Processing Box 29044 131 South Dearborn 6th Floor 1-855-577-6317. Hot Springs, AR 71903 Box 29044 Hot Springs, AR 71903 Chicago, IL 60603. Fax: 1-855-678-6976. Hot Springs, AR 71903 OptumRx Indiana Drug Rebate Operations First-Class Mail PA Fax: 1-855-577-6384. FFS Pharmacy Benefit 5775 Peachtree-Dunwoody Rd., Suite C-600 OptumRx Claims OptumRx PA Management Inquiries Atlanta, GA 30342 26594 Network Place Box 44085 Chicago, IL 60673-1265. Indianapolis, IN 46244-0085. Version 1 March 2021. IHCP Quick Reference Guide Contact Information Managed Care Enrollment Hoosier Healthwise Healthy Indiana Plan (HIP) Hoosier Care Connect Broker 1-800-889-9949 1-877-438-4479 1-866-963-7383. Helplines Hoosier Anthem MDwise MHS CareSource Healthwise Provider Services Provider Services Provider Services Provider Services 1-866-408-6132 1-800-356-1204 1-877-647-4848 1-844-607-2831.

5 Fax: 1-866-408-7087 Fax: 1-877-822-7190 or Fax: 1-866-753-7240. (317) 829-5530 Member Services Member Services Member Services 1-844-607-2829. 1-866-408-6131 Member Services 1-877-647-4848. 1-800-356-1204 Claims Claims Claims CareSource Claims Anthem Reimbursement Claims MHS Payment Policies 1-844-607-2831. Hoosier Healthwise Claims Prior Authorization (PA) Medical and 1-800-356-1204 Prior Authorization Medical and SUD Prior Authorization Medical and SUD. Substance Use Disorder (SUD) MHS PA CareSource PA. Anthem PA Prior Authorization Medical and SUD 1-877-647-4848 1-844-607-2831. 1-866-408-6132 MDwise PA Fax (Physical Health Inpatient and Fax: 1-844-432-8924. Fax (Physical Health Inpatient and 1-888-961-3100 Outpatient: 1-866-912-4245. Outpatient): 1-866-406-2803 Fax: 1-888-465-5581 Fax (Behavioral Health Inpatient): Pharmacy Services Fax (Behavioral Health Inpatient): 1-844-288-2591 PBM Claims: CVS Health 1-877-434-7578 Pharmacy Services Fax (Behavioral Health Outpatient): Pharmacy Information Fax (Behavioral Health Outpatient): PBM: MedImpact 1-866-694-3649 Claims: 1-800-980-6765.)

6 1-866-877-5229 Pharmacy Information PA: 1-844-607-2831. Claims: 1-844-336-2677 Pharmacy Services PA Fax: 1-844-432-8924. Pharmacy Services PA: 1-800-788-2949 PBM Claims: CVS Health PBM: IngenioRx PA Fax: 1-858-790-7100 PBM PA: US Script Dental Services Pharmacy Information Pharmacy Information CareSource Dental Claims: 1-833-235-2023 Dental Services Claims: 1-800-378-0815 1-844-607-2831. PA: 1-866-408-6132 DBM: DentaQuest PA: 1-866-399-0928. DentaQuest Provider Portal Vision Services PA Fax (Retail Pharmacy): 1-844-864-7860 PA Fax (Standard): 1-866-399-0929 VBM: Versant Health/Superior Vision PA Fax (Medical Injectable): 1-888-209-7838 1-855-453-5286 PA Fax (Specialty): 1-855-678-6976. Fax: 1-262-834-3589 Help for Pharmacists: 1-833-236-6191 Provider Customer Service: Dental Services Dental Services DBM: Envolve Dental 1-877-235-5317. DBM: DentaQuest Envolve Dental Provider Portal Utilization Management (PA): 1-855-609-5157 1-888-273-2121.

7 DentaQuest Provider Portal Fax: 1-855-313-3106. 1-855-453-5286. Vision Services Fax: 1-262-834-3589. VBM: Envolve Vision Vision Services VBM: Superior Vision 1-866-599-1774 (Hoosier Healthwise and Hoosier Care Connect). 1-877-235-5317 1-844-820-6523 (HIP). Fax: (518) 556-7707. Version 2 March 2021. IHCP Quick Reference Guide Contact Information Healthy Anthem MDwise MHS CareSource Indiana Provider Services Provider Services Provider Services Provider Services Plan 1-844-533-1995 1-800-356-1204 1-877-647-4848 1-844-607-2831. Fax: 1-866-408-7087 Fax: 1-877-822-7190 Fax: 1-866-753-7240. Member Services Member Services Member Services Member Services 1-844-607-2829. 1-866-408-6131 1-800-356-1204 1-877-647-4848. Claims Claims Claims Claims CareSource Claims Anthem Reimbursement HIP Claims MHS Payment Policies 1-844-607-2831. Prior Authorization Medical and Substance Prior Authorization Medical and Prior Authorization Medical and SUD Prior Authorization Medical and SUD.

8 Use Disorder (SUD) SUD MHS PA CareSource PA. Anthem PA MDwise PA 1-877-647-4848 1-844-607-2831. 1-844-533-1995 1-888-961-3100 Fax (Physical Health Inpatient and Fax: 1-844-432-8924. Fax (Physical Health Inpatient and Fax (Physical Health Inpatient and Outpatient): 1-866-912-4245. Outpatient): 1-866-406-2803 Outpatient): 1-866-613-1642 Fax (Behavioral Health Inpatient): Pharmacy Services Fax (Behavioral Health Inpatient): Fax (Behavioral Health Inpatient): 1-844-288-2591 Pharmacy Information 1-877-434-7578 1-866-613-1631 Fax (Behavioral Health Outpatient): PBM Claims: CVS Health Fax (Behavioral Health Outpatient): Fax (Behavioral Health Outpatient): 1-866-694-3649 Claims: 1-800-342-5441. 1-866-877-5229 1-866-613-1642 PA: 1-844-607-2831. Pharmacy Services PA Fax: 1-844-432-8924. Pharmacy Services Pharmacy Services Pharmacy Information PBM: IngenioRx Pharmacy Resources PBM Claims: CVS Health Dental Services Pharmacy Information PBM: MedImpact PBM PA: US Script CareSource Dental Claims: 1-833-205-6007 Claims: 1-844-336-2677 Claims: 1-800-311-0557 1-844-607-2831.

9 PA: 1-844-533-1995 PA: 1-800-788-2949 PA: 1-866-399-0928 Vision Services PA Fax (Retail Pharmacy): 1-844-864-7860 PA Fax: 1-858-790-7100 PA Fax: 1-866-399-0929 (standard). VBM: Versant Health/Superior Vision PA Fax (Medical Injectable): 1-888-209-7838 PA Fax: 1-855-678-6976 (specialty) Help for Pharmacists: 1-833-236-6191 Dental Services DBM: DentaQuest Dental Services Provider Customer Service: Dental Services DBM: Envolve Dental 1-877-235-5317. DentaQuest Provider Portal DBM: DentaQuest Envolve Dental Provider Portal Utilization Management (PA): 1-855-453-5286. 1-855-609-5157 1-888-273-2121. DentaQuest Provider Portal Fax: 1-262-834-3589. Fax: 1-855-313-3106. 1-855-453-5286 Vision Services Fax: 1-262-834-3589 VBM: Envolve Vision Vision Services 1-866-599-1774 (Hoosier Healthwise and VBM: Superior Vision Hoosier Care Connect). 1-844-820-6523 (HIP).

10 1-877-235-5317. Fax: (518) 556-7707. Version 3 March 2021. IHCP Quick Reference Guide Contact Information Hoosier Care Anthem MHS UnitedHealthcare Connect Provider Services Provider Services Provider Services 1-844-284-1798 1-877-647-4848 1-877-610-9785. Fax: 1-888-859-3046 Fax: 1-866-753-7240. Member Services Member Services Member Services 1-844-284-1797 1-877-647-4848 1-800-832-4643. Claims Claims Claims Anthem Reimbursement MHS Payment Policies 1-866-408-6132 1-877-610-9785. Prior Authorization Medical and SUD. Prior Authorization Medical and Substance Use MHS PA Prior Authorization Medical and SUD. Disorder (SUD) 1-877-647-4848 Anthem PA Fax (Physical Health Inpatient and Outpatient): 1-877-610-9785. 1-844-284-1798 1-866-912-4245 Fax: 1-844-897-6514. Fax (Physical Health Inpatient and Outpatient): Fax (Behavioral Health Inpatient): 1-844-288-2591.