How to Fill Out and Submit the Indiana Medicaid Prior Authorization Form

The Indiana Medicaid prior authorization form is the IHCP Universal Prior Authorization Request Form, a single PDF used across every Indiana Medicaid program. Download it from in.gov/medicaid/providers/files/pa-form.pdf, select the entity that must authorize the service, complete every applicable field, attach clinical records showing medical necessity, and submit through the Atrezzo Provider Portal or the fax number assigned to the member’s plan.¹ The current version is 10.1, dated May 2026.

The same form covers members of the Healthy Indiana Plan (HIP), Hoosier Healthwise, Hoosier Care Connect, and the fee-for-service program. A radio button at the top of the form routes the request to the correct authorizing entity, so the form itself does not change — only your selection does.

Completing the Form Section by Section

Incomplete submissions are a common reason requests stall. The form warns that medical documentation must be included for the request to be reviewed for medical necessity.² Work through each block in order.

Pick the Authorizing Entity First

Before you fill in anything else, select the radio button for the entity responsible for authorizing the service. For members in a managed care plan, that is their MCE: Anthem, CareSource, MHS, or UnitedHealthcare. For services carved out of managed care and delivered as fee-for-service, select Acentra Health, the state’s fiscal agent.³ Choosing the wrong entity routes the request to an organization that cannot act on it. If you are unsure of the member’s plan, verify enrollment through the IHCP Provider Healthcare Portal before submitting.

Patient Information

Enter the member’s IHCP Member ID, date of birth, full name, address, and phone number. The same section captures the member’s primary medical provider (PMP) name, NPI, and phone number.

Provider Information

The form collects up to three provider roles. The ordering, prescribing, or referring (OPR) provider block needs that provider’s NPI. The requesting provider block needs an NPI or provider ID, taxonomy code, taxpayer identification number (TIN), name, and address. If a different provider will perform the service, complete the rendering provider block with their NPI, TIN, name, address, phone, and fax. A separate preparer’s information block captures the name, phone, and fax of the staff member who filled out the form.²

Diagnosis, Assignment Category, and Service Lines

Enter up to three ICD diagnostic codes linking the member’s condition to the requested service. ICD coding is required. Then select the assignment category that best describes the service:

DME, purchased or rented (wheelchairs, oxygen equipment, hospital beds, and similar items)
Home health or hospice (skilled nursing visits, hospice care)
Inpatient, observation, or outpatient facility services
Therapy (occupational, physical, or speech)
Transportation (non-emergency medical transportation)
Office visit or other, for anything that does not fit above

The service detail rows require the procedure or service code (CPT or HCPCS), up to four modifiers, a written service description, the rendering provider’s taxonomy, place-of-service code, units, and dollar amounts. Enter the start and stop dates for the requested service period. A qualified practitioner must sign and date the bottom.²

Clinical Documentation That Supports Medical Necessity

The form by itself is not enough. Every submission must include medical records that back up the medical necessity of the requested service. What qualifies depends on the service: physician progress notes, lab results, imaging reports, or a treatment plan explaining why less intensive alternatives would not work. For durable medical equipment, a written order from a physician, optometrist, or dentist is always required, and recent progress notes from a provider who has treated the patient within the last six months may also be needed.⁴

Medical necessity is the single most common reason prior authorization requests are denied across all service categories.⁵ That usually means the documentation did not make a clear enough case, not that the service was inappropriate. Be specific in the clinical justification: state what the member’s condition is, what has already been tried, and why the requested service is the appropriate next step.

How and Where to Submit

Indiana Medicaid accepts prior authorization requests through three channels: the online Atrezzo Provider Portal, fax, and mail.¹ Telephone requests are also accepted in some circumstances.

Atrezzo Provider Portal

The Atrezzo Provider Portal at atrezzo.acentra.com is the primary electronic submission method. The IHCP Provider Healthcare Portal at portal.indianamedicaid.com links directly to Atrezzo under its “Authorization Portal” heading.⁶ You can upload the completed form and all supporting documentation at once and track the status of the request afterward.

Fax Numbers by Plan

If you fax the request, use the number assigned to the member’s plan. Using the wrong number sends your request to an entity that cannot process it:

Fee-for-service, Acentra Health: 800-261-2774
Anthem (HIP, Hoosier Healthwise, Hoosier Care Connect): 866-406-2803
CareSource (HIP, Hoosier Healthwise): 844-432-8924
MHS (HIP, Hoosier Healthwise, Hoosier Care Connect): 866-912-4245
UnitedHealthcare (Hoosier Care Connect): 844-897-6514

These numbers appear on the form itself, and the IHCP Quick Reference Guide lists mailing addresses for each entity for providers who cannot use electronic or fax submission.²

When to Expect a Decision

Under Indiana legislation enacted in 2025, insurers must respond to urgent prior authorization requests within 24 hours and to non-urgent requests within 48 hours.⁷ The same law requires insurers to use peer-to-peer review during appeals of denials and to honor a prior authorization from a patient’s previous insurer for at least 90 days after the member switches plans. Insurers must also publicly post online which services require prior authorization.

Reviewers may request additional information if the initial documentation is thin, and that back-and-forth extends the overall timeline. Thorough clinical records on the first submission are the best defense against delay. Decisions typically come back through the Atrezzo Portal for electronic submissions and by fax to the provider’s office, with a written notice sent to the member.

Retroactive Prior Authorization

Prior authorization is meant to happen before the service. Indiana Medicaid allows retroactive authorization only in a few defined situations:⁸

Pending or retroactive member eligibility. The request must be submitted within 12 months of the date the caseworker entered the eligibility information. For hospice, the request must be submitted within one year of the date nursing facility level of care is approved.
Out-of-state provider not yet enrolled in IHCP at the time services were rendered.
Administrative or mechanical errors caused by the fiscal agent or a county DFR office.
Out-of-state transportation, including transport to or from an out-of-state area, services by an out-of-state provider, or airline and air ambulance transport. The request must be submitted within 12 months of the service date.
Provider unaware of the member’s eligibility, allowed only if the provider’s records show the member refused or was physically unable to provide their IHCP Member ID, the provider can prove they pursued reimbursement from the member until discovering IHCP eligibility, and the request is submitted within 60 calendar days of that discovery.
Procedure uncertain until performed, where the exact service could not be determined ahead of time.

When a retroactive authorization is approved, the timely filing limit for the associated claim extends to 180 days from the date the retroactive PA was approved. A copy of the approved PA marked “retroactive prior authorization” must accompany the claim.⁸

If the Request Is Denied

A denial can be challenged, but the deadlines are tight. The first step is an administrative review from the entity that denied the request. You have seven days from the date you receive the denial notice to submit the review request, and for managed care members you send it to the member’s MCE. The entity must issue a decision within seven days of receiving all necessary documentation.⁹

Peer-to-peer review is now part of the appeal process by law. Providers must respond to an adverse determination within 48 hours, and the reviewing entity will make efforts to hold the peer-to-peer within 48 hours of the request, excluding weekends and holidays.⁵ If the administrative review upholds the denial, a formal appeal to the Indiana Family and Social Services Administration is the next step, and managed care members must exhaust their MCE’s internal appeals process before going to FSSA. That appeal must be sent within 15 business days of receiving the administrative review decision.⁹

1
Indiana Medicaid. Prior Authorization – Indiana Medicaid for Providers
2
Indiana Medicaid. IHCP Universal Prior Authorization Request Form
3
Indiana Medicaid. Managed Care Health Plans – Indiana Medicaid Partners
4
Indiana Family to Family. Durable Medical Equipment
5
MHS Indiana. Prior Authorization – MHS Indiana
6
Indiana Medicaid. IHCP Provider Portal Home
7
ASCO. States Lead on Prior Authorization Reform
8
Indiana Health Coverage Programs. Prior Authorization Module
9
Indiana Department of Child Services. Indiana Medicaid Prior Authorization and Claim Reimbursement