All services, except pharmacy, lab and X-ray, must be approved by either a prior authorization (PA) or by a linkage of the provider to the participant for services related to the participant’s eligible medical condition. A PA confirms medical necessity and the relationship of the service to an eligible medical diagnosis. Services provided by a linked provider in their office do not require PA.
Providers are responsible for obtaining PA from the Children's Special Health Care Services (CSHCS) Program for covered services when necessary. Providers should contact the Prior Authorization Section by telephone and fax a copy of their evaluation or consultant records from the patient’s medical chart.
The Children’s Special Health Care Services (CSHCS) Program has developed a Request for Authorization form. The use of this form is required when submitting requests for prior authorization. You may print and make copies as necessary. Please complete and submit this form each time you request a prior authorization, along with any other necessary documentation. This form will help to streamline the authorization process and allow us to make a determination more quickly and efficiently.
The fax number is 1-317-233-1342; the telephone number is 1-317-233-1351 or 1-800-475-1355, PA option (Opt. 3)
Below is a list of services that require prior authorization to allow payment by CSHCS; however, this list is not all-inclusive.
- Inpatient services (hospitalizations)
- Equipment and supplies
- Specialized dental care
- Therapy (occupational, physical, speech, ABA)
- Home health care
- Emergency room services for covered conditions
- Specialized medical care for covered conditions
- Over-the-counter nutritional formulas or vitamins
Prior authorization is not a guarantee of payment. Although the prior authorization does confirm coverage of the service, the patient must be eligible on the date of service for the charges to be reimbursed. Additionally, the provider would need to submit a claim for the service on the appropriate claim form or electronic format. All claims would be subject to third party payment provisions as discussed in the “Reimbursement Considerations” section of the provider manual (the manual is under the Provider Relations section of our web page, page 8).
Authorization for Emergency Services
The provider must notify the CSHCS Program of emergency care and unscheduled hospitalizations within five (5) working days of the emergency care (does not include Saturdays, Sundays, or legal holidays). Emergency means an unexpected or sudden event or occurrence that requires immediate attention, intervention and medical care to prevent serious harm or loss of life. An authorization for payment may be written only after the PA Section receives the discharge summary or medical notes from the emergency room visit or other emergency care. Providers are responsible for mailing or faxing these documents to the program. Only services related to the eligible medical condition(s) will be authorized for reimbursement by the CSHCS Program.