The Indiana Health Coverage Programs (IHCP) requires prior authorization (PA) for certain covered services to document the medical necessity for those services.
Fee-for-Service Prior Authorization
Under the fee-for-service (FFS) delivery system, decisions to authorize, modify or deny requests for PA are based on medical reasonableness, necessity and other criteria in the Indiana Administrative Code (IAC), as well as IHCP-approved internal criteria. IHCP fee-for-service PA requests are reviewed on a case-by-case basis by the following entities:
- Gainwell Technologies reviews all FFS nonpharmacy PA requests:
- To determine whether a covered procedure code requires PA for members in the FFS delivery system, see the Outpatient Fee Schedule and Professional Fee Schedule, accessible from the IHCP Fee Schedules page.
- PA requests may be submitted to Gainwell online via the IHCP Provider Healthcare Portal; by mail or fax, using the appropriate PA request form; or (in some cases) by telephone at 800-457-4584, option 7.
Medical clearance forms and certification of medical necessity forms required with certain PA requests (as well as the PA request forms themselves, for mailed or faxed submissions) are available on the Forms page. Providers are responsible for using these tools to ensure accurate, timely PA review and claim processing. For detailed instructions regarding the FFS nonpharmacy PA procedures, see the Prior Authorization provider reference module and Best Practices: Nonpharmacy Prior Authorization.
- OptumRx reviews all FFS pharmacy PA requests:
- FFS pharmacy PA criteria, forms and additional information are available on the OptumRx Indiana Medicaid website at inm‑providerportal.optum.com.
- For detailed instructions regarding the FFS pharmacy PA process and procedures, see the Pharmacy Services provider reference module.
See the IHCP Quick Reference Guide for both Gainwell and OptumRx PA contact information.
Managed Care Prior Authorization
The managed care entities (MCEs) are responsible for processing all PA requests for services covered under the managed care delivery system, and for notifying Healthy Indiana Plan (HIP), Hoosier Care Connect and Hoosier Healthwise members about PA decisions.
To determine whether a procedure code requires PA for members enrolled in a managed care program, and for information about specific PA criteria, processes and procedures, contact the MCE with which the member is enrolled.
Contact information for each of the MCEs is available on the IHCP Quick Reference Guide.
Note: Some services are carved out of managed care and covered under the FFS delivery system for all IHCP members. See the Member Eligibility and Benefit Coverage provider reference module for a list of carved-out services.
Prior Authorization Status Information
Learn how the high-level PA status codes displayed on the IHCP Provider Healthcare Portal and reported in 278 transactions and by the Interactive Voice Response (IVR) system translate to the working statuses associated with each standard response. Providers should refer to their PA notification letters for additional information regarding the more detailed working status of a PA request.