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
- 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.
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.