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Prior Authorization Attachment Address Table
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The following table provides the Prior Authorization (PA) address
for each of the Care Management Organizations (CMO) as well as the Traditional
Medicaid fee for service vendor address for submission of PA request,
PA updates and PA attachments. Please note, that PA requests for carved out Risk Based Managed Care
(RBMC) services, Medicaid Select, Hospice, and Traditional Medicaid members as well as any
other PA requests for services outside of RBMC and Care Select should be submitted to the
Fee For Service address noted below for review.
This table provides address information
in a real-time format to ensure that providers have the most current address information for
submission of these documents. The Quick Reference Guide that is available to the provider
community in the Indiana Health Coverage Program (IHCP) monthly newsletter also contains PA
document submission addresses. The information in the table below supersedes any addresses
listed in the Quick Reference Guide and should be utilized to ensure accurate mailings of PA
information to the IHCP Prior Authorization department within these organizations. The UMO ID
column is for use on the HIPAA 278 transaction. If you submit a HIPAA 278 transaction please use the correct UMO ID.
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Prior Authorization Attachment Address Table
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Report Date:
11/22/2008 5:41:56 AM
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Member's Current CMO
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Send PA Attachments To
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Toll Free Phone
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Fax Number
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UMO ID
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| ADVANTAGE HEALTH SOLUTIONS INC |
ADVANTAGE HEALTH SOLUTIONS - CS
ATTN: PRIOR AUTHORIZATION DEPT
PO BOX 80068
INDIANAPOLIS, IN 46280 |
800-784-3981
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800-689-2759
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ADVCMO |
| FEE FOR SERVICE |
ADVANTAGE HEALTH SOLUTIONS-FFS
ATTN: PRIOR AUTHORIZATION DEPT
PO BOX 40789
INDIANAPOLIS, IN 46240 |
800-269-5720
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800-689-2759
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ADVFFS |
| MDWISE |
MDWISE, INC
ATTN: PRIOR AUTHORIZATION DEPT
PO BOX 44214
INDIANAPOLIS, IN 46244-0214 |
866-440-2449
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877-822-7186
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MDWCMO |
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