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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. To determine whether a covered procedure code requires PA for members in the fee-for-service (FFS) delivery system, see the Outpatient and Professional Fee Schedules, accessible from the IHCP Fee Schedules page. To determine whether a procedure code requires PA for members enrolled in managed care programs, contact the managed care entity (MCE) with which the member is enrolled. See the IHCP Quick Reference Guide for PA contact information for both the FFS and the managed care systems.

Fee-For-Service Prior Authorization

Gainwell Technologies (formerly DXC Technology) reviews all IHCP fee-for-service nonpharmacy PA requests on a case-by-case basis. Decisions to authorize, modify, or deny requests are based on medical reasonableness, necessity, and other criteria in the Indiana Administrative Code (IAC), as well as IHCP-approved internal criteria. PA request forms, as well as medical clearance and certifications of medical necessity forms for filing FFS requests, 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 PA process and procedures, see the Prior Authorization provider reference module and Best Practices: Nonpharmacy Prior Authorization.

OptumRx reviews all IHCP fee-for-service pharmacy PA requests. FFS 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.

Managed Care Prior Authorization

The MCEs are responsible for processing medical and pharmacy PA requests for managed care members enrolled in Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise and for notifying members about PA decisions. For information about PA criteria, processes, and procedures, contact the MCE with which the member is enrolled.

Contact information, as well as links to tools and guidelines for each of the MCEs, is available on the IHCP Quick Reference Guide.

Prior Authorization Status Information

Learn how the high-level PA status codes displayed on the IHCP Provider Healthcare Portal (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.

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