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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. 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plan, unless the service is carved out [delivered as fee-forservice].)  \n\n| Fee-for-Service | Acentra Health | P: 866-725-9991 | F: 800-261-2774 |\n| --- | --- | --- | --- |\n| Hoosier\u003Cbr>Healthwise | Anthem Hoosier Healthwise | P: 866-408-6132 | F: 866-406-2803 |\n|  | CareSource Hoosier Healthwise | P: 844-607-2831 | F: 844-432-8924 |\n|  | MHS Hoosier Healthwise | P: 877-647-4848 | F: 866-912-4245 |\n| Healthy Indiana\u003Cbr>Plan (HIP) | Anthem HIP | P: 844-533-1995 | F: 866-406-2803 |\n|  | CareSource HIP | P: 844-607-2831 | F: 844-432-8924 |\n|  | MHS HIP | P: 877-647-4848 | F: 866-912-4245 |\n| Hoosier Care\u003Cbr>Connect | Anthem Hoosier Care Connect | P: 844-284-1798 | F: 866-406-2803 |\n|  | MHS Hoosier Care Connect | P: 877-647-4848 | F: 866-912-4245 |\n|  | UnitedHealthcare | P: 877-610-9785 | F: 844-897-6514 |\n| Indiana PathWays for Aging | Anthem PathWays | P: 844-284-1798 | F: 866-406-2803 |\n|  | Humana PathWays | P: 866-274-5888 | F: 502-324-6376 |\n|  | UnitedHealthcare PathWays | P: 877-610-9785 | F: 844-897-6514 |\n\nPlease complete all appropriate fields.  \n\n| Patient Information |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| IHCP Member ID: |  |  |  |  |  |  |\n| Date of Birth: |  |  |  |  |  |  |\n| Patient Name: |  |  |  |  |  |  |\n| Address: |  |  |  |  |  |  |\n| City/State/ZIP Code: |  |  |  |  |  |  |\n| Patient/Guardian Phone: |  |  |  |  |  |  |\n| PMP Name: |  |  |  |  |  |  |\n| PMP NPI: |  |  |  |  |  |  |\n| PMP Phone: |  |  |  |  |  |  |\n| Ordering, Prescribing or Referring (OPR) Provider Information |  |  |  |  |  |  |\n| OPR Provider NPI: |  |  |  |  |  |  |\n| Medical Diagnosis\u003Cbr>(Use of ICD Diagnostic Code Is Required) |  |  |  |  |  |  |\n| Dx1 |  |  | Dx2 |  | Dx3 |  |\n| Assignment Category |  |  |  |  |  |  |\n| Please check the requested assignment category below: |  |  |  |  |  |  |\n| DME-Purchased\u003Cbr>DME-Rented Home Health\u003Cbr>Hospice Inpatient |  | Observation\u003Cbr>Office Visit Occupational Therapy Outpatient\u003Cbr>Physical Therapy |  |  | Speech Therapy Transportation Other |  |\n\n\n| Requesting Provider Information |\n| --- |\n| Requesting Provider NPI/Provider ID: |\n| Taxonomy: |\n| Taxpayer Identification Number (TIN) : |\n| Provider Name: |\n| Provider Address: |\n| City/State/ZIP Code: |\n| Rendering Provider Information |\n| Rendering Provider NPI/Provider ID: |\n| TIN: |\n| Name: |\n| Address: |\n| City/State/ZIP Code: |\n| Phone: |\n| Fax: |\n| Preparer’s Information |\n| Name: |\n| Phone: |\n| Fax: |\n\n\n| 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 |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n\nIHCP Prior Authorization Request Form  \nVersion 10.1, May 2026 Page 1 of 2  \nNotes:  \nPLEASE NOTE: Your request MUST include medical documentation to be reviewed for medical necessity.  \nSignature of Qualified Practitioner  Date:    \nSee the IHCP Quick Reference Guide for information about where to mail this form.  \nIHCP Prior Authorization Request Form  \nVersion 10.1, May 2026 Page 2 of 2","cbCaioqC5EeyRpNf","https://ap.wps.com/l/cbCaioqC5EeyRpNf","pdf",290946,"English","# Authorization Entity Selection\n# Patient Information\n# Ordering/Prescribing/Referring Provider Information\n# Requesting Provider Information\n# Rendering Provider Information\n# Preparer’s Information\n# Service Request Details\n## Request Line Items","[{\"question\":\"Which entity should be selected for authorization, and what exception applies?\",\"answer\":\"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.\"},{\"question\":\"What information is required in the Patient Information section?\",\"answer\":\"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.\"},{\"question\":\"What must be included for the request to be reviewed for medical necessity?\",\"answer\":\"The request MUST include medical documentation to be reviewed for medical necessity, and a Qualified Practitioner signature with a date is required.\"}]","Indiana Health Coverage Programs Prior Authorization Request Form - Version 10.1 - May 2026 | PDF",1789621342]