Prior Authorization (PA)
Prior authorization (PA) is required for certain covered
services to document the medical necessity for those services. To
determine if a procedure code requires PA for members in the
fee-for-service (FFS) system, access the provider Fee
Schedule. Detailed instructions regarding the FFS PA
process and procedures are provided in Chapter 6 of the
IHCP Provider Manual, as well as on the Best Practices: Nonpharmacy
PA page on this website. To determine if a procedure code
requires PA for members in the risk-based managed care (RBMC)
system, see the guidelines set forth by the member's managed care
Submitting a Nonpharmacy PA Request - FFS
When you need a nonpharmacy PA for a member in the FFS system,
complete the appropriate form and submit it to ADVANTAGE Health
Solutions(SM). See the IHCP Quick Reference Guide
for submission information. For PA request forms, see the Forms page on this website. PAs can be initiated
by fax, telephone, and U.S. mail, and through Web interChange.
Submission by fax, telephone, or Web interChange holds the date and
time of the request, and thus helps mitigate concerns about
retroactive PA in certain situations when full documentation is
successfully submitted later.
Each provider is mailed a prior authorization decision letter
that includes an Indiana Medicaid Notice of Appeal Rights. The same
letter is mailed to the member. This notification gives providers
as well as members and families information about steps they can
take to appeal the PA decision. To access a copy of the
notification letter, please select one of the versions below.
For Notice of Appeal Rights: (English) (Spanish)
The Notice of Appeal Rights states that a member can download the
following appeal form to file an appeal.
For a Medicaid Appeal Request Form, click
Submitting Pharmacy PA Requests - FFS
(Includes RBMC Carve-Outs)
When you need a pharmacy PA for a member in the FFS system,
including managed care members whose pharmacy benefits are carved
out of RBMC, see the Pharmacy Services
quick link on this website. For more information, see Chapter 9 of the
IHCP Provider Manual.
Submitting PA Requests - RBMC
When you need a PA for a member in the RBMC system, including
pharmacy PAs for members whose pharmacy benefits have been carved
into RBMC, follow the guidelines set forth by the appropriate MCE.
For links to tools and guidelines for each of the IHCP's MCE
partners, see the IHCP Quick