Prior Authorization (PA)

Overview

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 entity (MCE).

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), as shown in the Prior Authorization Attachment Address Table. 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. You can appeal a nonpharmacy PA decision. See Chapter 6 of the IHCP Provider Manual for instructions.

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. Links to tools and guidelines for each of Indiana's MCE partners follow.