Indiana Health Coverage Programs Prior Authorization Request Form - Version 10.1 - May 2026

Sep 17, 2026

Uploaded by Graffin

Indiana Health Coverage Programs Prior Authorization Request Form collects detailed member, patient, and provider information to support prior authorization decisions. It instructs submitters to select the authorization entity and complete required demographic fields, diagnosis codes, assignment category, and request provider details including NPI and TIN. The form also provides a structured request line-item table for procedure/service codes, modifiers, service descriptions, place of service, units, and dollar amounts. It requires medical documentation and includes a Qualified Practitioner signature and date.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Authorization Entity Selection

Patient Information

Ordering/Prescribing/Referring Provider Information

Requesting Provider Information

Rendering Provider Information

Preparer’s Information

Service Request Details

Request Line Items

Indiana Health Coverage Programs Prior Authorization Request Form Select the radio button of the entity that must authorize the service.(For managed care, check the member’s plan, unless the service is carved out [delivered as fee-forservice].) | Fee-for-Service | Acentra Health | P: 866-725-9991 | F: 800-261-2774 | | --- | --- | --- | --- | | Hoosier
Healthwise | Anthem Hoosier Healthwise | P: 866-408-6132 | F: 866-406-2803 | | | CareSource Hoosier Healthwise | P: 844-607-2831 | F: 844-432-8924 | | | MHS Hoosier Healthwise | P: 877-647-4848 | F: 866-912-4245 | | Healthy Indiana
Plan (HIP) | Anthem HIP | P: 844-533-1995 | F: 866-406-2803 | | | CareSource HIP | P: 844-607-2831 | F: 844-432-8924 | | | MHS HIP | P: 877-647-4848 | F: 866-912-4245 | | Hoosier Care
Connect | Anthem Hoosier Care Connect | P: 844-284-1798 | F: 866-406-2803 | | | MHS Hoosier Care Connect | P: 877-647-4848 | F: 866-912-4245 | | | UnitedHealthcare | P: 877-610-9785 | F: 844-897-6514 | | Indiana PathWays for Aging | Anthem PathWays | P: 844-284-1798 | F: 866-406-2803 | | | Humana PathWays | P: 866-274-5888 | F: 502-324-6376 | | | UnitedHealthcare PathWays | P: 877-610-9785 | F: 844-897-6514 | Please complete all appropriate fields. | Patient Information | | | | | | | | --- | --- | --- | --- | --- | --- | --- | | IHCP Member ID: | | | | | | | | Date of Birth: | | | | | | | | Patient Name: | | | | | | | | Address: | | | | | | | | City/State/ZIP Code: | | | | | | | | Patient/Guardian Phone: | | | | | | | | PMP Name: | | | | | | | | PMP NPI: | | | | | | | | PMP Phone: | | | | | | | | Ordering, Prescribing or Referring (OPR) Provider Information | | | | | | | | OPR Provider NPI: | | | | | | | | Medical Diagnosis
(Use of ICD Diagnostic Code Is Required) | | | | | | | | Dx1 | | | Dx2 | | Dx3 | | | Assignment Category | | | | | | | | Please check the requested assignment category below: | | | | | | | | DME-Purchased
DME-Rented Home Health
Hospice Inpatient | | Observation
Office Visit Occupational Therapy Outpatient
Physical Therapy | | | Speech Therapy Transportation Other | | | Requesting Provider Information | | --- | | Requesting Provider NPI/Provider ID: | | Taxonomy: | | Taxpayer Identification Number (TIN) : | | Provider Name: | | Provider Address: | | City/State/ZIP Code: | | Rendering Provider Information | | Rendering Provider NPI/Provider ID: | | TIN: | | Name: | | Address: | | City/State/ZIP Code: | | Phone: | | Fax: | | Preparer’s Information | | Name: | | Phone: | | Fax: | | Start Date | Stop Date | Procedure/ Service Code | Mod 1 | Mod 2 | Mod 3 | Mod 4 | Service Description | Taxonomy | Place of Service (POS) Code | Units | Dollars | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | IHCP Prior Authorization Request Form Version 10.1, May 2026 Page 1 of 2 Notes: PLEASE NOTE: Your request MUST include medical documentation to be reviewed for medical necessity. Signature of Qualified Practitioner Date: See the IHCP Quick Reference Guide for information about where to mail this form. IHCP Prior Authorization Request Form Version 10.1, May 2026 Page 2 of 2

FAQs

Which entity should be selected for authorization, and what exception applies?

Select the radio button of the entity that must authorize the service; for managed care, check the member’s plan unless the service is carved out and delivered as fee-for-service.

What information is required in the Patient Information section?

The form requests IHCP Member ID, date of birth, patient name and address, city/state/ZIP, patient/guardian phone, PMP name, PMP NPI, and PMP phone.

What must be included for the request to be reviewed for medical necessity?

The request MUST include medical documentation to be reviewed for medical necessity, and a Qualified Practitioner signature with a date is required.

Sep 17, 2026

Uploaded by Graffin