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Prior Authorization

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 necessity and other criteria in federal and state code, as well as IHCP-approved internal criteria. IHCP fee-for-service prior authorization (PA) requests are reviewed on a case-by-case basis by the following entities:

  • Optum Rx reviews all FFS pharmacy PA requests:
    • FFS pharmacy PA criteria, forms and additional information are available on the Optum Rx Indiana Medicaid website at inm‑
    • For detailed instructions regarding the FFS pharmacy PA process and procedures, see the Pharmacy Services provider reference module.
  • Acentra Health 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 Acentra Health online via the Atrezzo Provider Portal; by fax or mail, using the appropriate PA request form; or by telephone.

      Note: 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.

See the IHCP Quick Reference Guide for both Acentra Health and Optum Rx 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.

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