best practices: Nonpharmacy Prior Authorization

To make prior authorization (PA) for nonpharmacy services go as smoothly as possible, here are some helpful hints:

  • Remember to verify member eligibility to ensure that the PA request is submitted to the correct vendor for review. PA requests sent to the wrong vendor are rejected. See the IHCP Quick Reference Guide to find PA contact information for all programs
  • PA requests and documentation that have been faxed multiple times are often illegible when received. When submitting fax documents to the PA vendor, it may be helpful to also submit an unsigned clear copy of the request for review marked "for clarity only." The clarity document does not require a signature.
  • Please remember to include the PA number on all telephone or system PA updates to prevent duplicate PA requests in the PA database. Duplicate requests in the database result in the mailing of multiple decision letters.
  • PA forms submitted by providers require a physician's signature and date. PA forms that are not signed and dated will suspend, delaying services.
  • Ensure that the National Provider Identifier (NPI) or provider number, member ID number, and other information are correct on PA forms. Remember that the ICD diagnosis code must be listed. Service codes must be valid, including modifiers.
  • Providers should verify that their Mail To addresses are correct in IndianaAIM to ensure that letters are mailed to the appropriate location. Providers with multiple sites should append the appropriate alpha location code to the end of their Legacy Provider Identifiers (LPIs) for each site. Providers may verify the accuracy of their Mail To addresses via the Provider Profile feature of Web interChange; go to Access Provider Profile.
  • Medical clearance forms and certifications of medical necessity are located on the  Forms page on this site. Remember to complete and attach these forms, as applicable, for easier processing.
  • Fax each IHCP PA request separately. Each PA request should be sent with its own cover sheet. Providers should keep the fax confirmation in case of  fax transmission issues.
  • When a PA is suspended for additional information, please be sure to submit the additional documentation within 30 days to avoid an automatic system denial.
  • Please remember to write "Retro Request" and the reason for the retroactive request on any PA request for past dates of service. Otherwise, the PA request will be modified to the date of service received. Please see the Prior Authorization provider reference module on the Provider Reference Materials page for more information regarding retroactive PA.
  • When requests are "returned to provider (RTP)," please include the RTP form when resubmitting the request to the PA vendor.
  • The decision date printed on the PA notification letter is the date the PA was originally entered into the PA database, not the date the decision was rendered. For example, a PA is received and entered into the system May 10; however, a decision is not rendered until May 17. The decision date included on the letter is May 10, the date the PA is entered into the system.

PHARMACY PA

For information about pharmacy prior authorization, contact the appropriate pharmacy benefits manager based on the member's enrollment. See the IHCP Quick Reference Guide to find the Pharmacy PA contact information for all programs.