Prior Authorization (PA)

Prior authorization (PA) is required for certain covered services to document the medical necessity for those services. To determine whether a procedure code requires PA for members in the fee-for-service (FFS) delivery system, access the Indiana Health Coverage Programs (IHCP) provider Fee Schedule. To determine whether a procedure code requires PA for members enrolled in managed care programs, contact the managed care entity (MCE) with which the member is enrolled. See the IHCP Quick Reference Guide for PA contact information for both the FSS and the managed care systems.

Fee-for-Service Prior Authorization

Cooperative Managed Care Services (CMCS) reviews all IHCP nonpharmacy FFS PA requests on an individual, case-by-case basis. Decisions to authorize, modify, or deny a request are based on medical reasonableness, necessity, and other criteria in the Indiana Administrative Code (IAC), as well as IHCP-approved internal criteria. PA request forms, as well as medical clearance and certifications of medical necessity forms for filing FFS requests, are available on the Forms page on this site. Providers are responsible for using these tools to ensure accurate, timely PA review and claims processing. For detailed instructions regarding the FFS PA process and procedures, see the Prior Authorization provider reference module and Best Practices: Nonpharmacy PA on this website.

OptumRx reviews all pharmacy FFS PA requests, including PA for pharmacy services carved out of managed care plans and processed through the FFS delivery system. For detailed instructions regarding the FFS pharmacy PA process and procedures, see the Pharmacy Services provider reference module. PA criteria, forms, and other information can be found under the Pharmacy Services quick link on this site.

Managed Care Prior Authorization

The Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise MCEs are responsible for processing nonpharmacy PA requests for managed care members and notifying members about PA decisions. For information about PA criteria, processes, and procedures, members in these programs contact the MCE with which they are enrolled.

Pharmacy benefits for HIP and Hoosier Care Connect members are managed by the enrolling managed care plans. For information on PA criteria, processes, and procedures for service rendered to members in these programs, contact the MCE with which the member is enrolled.

Contact information, as well as links to tools and guidelines for each of the MCEs, is available on the IHCP Quick Reference Guide.