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.
- PA requests and documentation that have been faxed multiple
times are often illegible when received. HP recommends that
providers 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 write the PA number on all TPA (telephone
PA) or system updates. This prevents replication
of requests into the PA database, causing duplications and the
mailing of multiple decision letters.
- PA forms submitted by providers require a physician's
signature and date. The signature prevents the PA from
being suspended and delaying services.
- Ensure that the National Provider Identifier (NPI) or provider
number, member ID number, and other information are
correct on PA forms. Remember the International Classification of
Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis
code must be listed. Service codes must be valid, including
- Providers should verify through HP that their Mail To
addresses are correct in IndianaAIM to ensure 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 Identifier (LPI) for each site. Providers may
verify the accuracy of their Mail To address via the Provider
Profile feature of Web interChange - go to Access Provider
Profile on the indianamedicaid.com home page.
- IHCP Standard Medical Clearance and Certificate of Medical
Necessity forms are located on the Forms page of indianamedicaid.com. Remember to
complete and attach these forms, as applicable, for easier
- Fax all IHCP requests separately. Each PA request should be
sent with a separate cover sheet. Providers should keep the fax
confirmation for all fax transmission issues.
- When a PA is suspended for additional information, please be
sure to submit the additional documentation within 30 days to
avoid 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 refer to Chapter 6 of the IHCP
Provider Manual for more information regarding retroactive PA. When
requests are resubmitted to the PA vendor after
being "returned to provider (RTP)," please include
the return to provider (RTP) form when resubmitting.
- The decision date printed on the prior authorization (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 May10;
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
For pharmacy claims PA, please call Affiliated Computer Services
(ACS) at 1-866-879-0106.