** Provider Memo: Physician Extenders (PE)  **

Provider Manual

• Indiana Provider Manual
• Indiana Covered Services & Authorization Grid

Administrative & Claims

• Chart Audit Form
• CMS-1500 Claim Form Instructions (HCFA)
• Medical Record Release Form
• Provider Complaint Form
• Provider Change Form
• UB-04 Claim Form Instructions
• W-9 (must accompany Provider Change Form)

Pharmacy Benefit

• Indiana Health Coverage Programs (IHCP) Preferred Drug List - Please select the ‘Pharmacy Services’ option, then select ‘Preferred Drug List’ to view the current listing.

Interpreter Request Form

• Interpreter Request Form

Cultural Competency Plan

• Cultural Competency Plan

Behavioral/Physical Health Form

• Behavioral/Physical Health Coordination Form

Outpatient Treatment Request (OTR) Form

• Outpatient Treatment Request (OTR) Form
• Outpatient Treatment Request (OTR) Tips Sheet
• Outpatient Treatment Request (OTR) – Training Presentation

Psych Testing Forms

 

• Psych Testing Form – Inpatient
• Psych Testing Form – Outpatient
• Indiana Neuropsych Testing Form

Clinical

• Clinical Practice Guidelines
• Practice Parameters
• Incident Report Form
• Intensive Outpatient/Day Treatment Form – Chemical Dependency
• Intensive Outpatient/Day Treatment Form – Mental Health
• SMART Goals – Fact Sheet

Medical Necessity Criteria

• 2011 Cenpatico Medical Necessity Criteria – Private Day Treatment and Community-Based Services
• *Note* – Effective February 1, 2011, Cenpatico, in association with InterQual, will begin enforcing new Medical Necessity Criteria for Behavioral Health. To see answers to Frequently Asked Questions (FAQ) regarding the change, please click here.

Best Practice Intervention Strategies Fact Sheets

• Alcohol and Other Drug (AOD)
• ADHD
• Adjustment Disorder
• Anxiety
• Bipolar
• Depression
• OCD
• ODDCD
• PTSD

Quick Reference Guides (QRGs)

• Indiana Quick Reference Guide (QRG)

Frequently Asked Questions (FAQs)

• Indiana FAQs

Brochures

• Post Hospitalization Incentive Program for Children
• Perinatal Brochure

School Based Counseling Forms

• School Based Counseling Fax Data Request
• School Based Counseling ROI form

State and Health Plan Contacts

• CHIRP Immunization Registry
• Hoosier Healthwise
• Indiana Family and Social Services Administration
• Indiana Medicaid
• Indiana State Department of Health
• Managed Health Services (MHS)
• Medicaid Select
• Vaccines for Children (VFC) Program