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‑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 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, Hoosier Healthwise and Indiana PathWays for Aging (PathWays) 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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