Department Of Insurance Prior Authorization Form In printable pdf download

Indiana Register

DEPARTMENT OF INSURANCE

February 25, 2015

Bulletin 214

Prior Authorization

This bulletin is directed to all insurers writing policies of accident and sickness insurance, as defined by

27-8-5-1; all health maintenance organizations (HMOs), as defined by

IC 27-13-1-19

and

27-13-36.2-2(a); all

third-party administrators, including those defined at

27-1-25-1(a) and those administering self-insured plans;

and other persons involved in reviewing claims and providing prior authorization for procedures. For purposes of

this bulletin, "prior authorization" will include any preapproval, preauthorization, prior approval, prior notification, or

similar requirement in a policy or contract; however, it does not include pretreatment payment estimates. The

purpose of this bulletin is to encourage all entities involved in the prior authorization process to use a common

form for prior authorization, thereby reducing costs to insurers and health care providers and avoiding

unnecessary delays for patients.

Prior authorization requests and subsequent approvals should be made in writing, which may include online

processes, electronic correspondence, facsimile correspondence, or other reproducible format, to avoid disputes

over oral representations. When a written request is not possible, prior authorization requests may be made by

phone or otherwise orally if the insurer allows. The Department has worked with representatives of insurers,

health care providers, and patients and has determined that the attached form, substantially similar to one already

in use in Texas, is a reasonable form for obtaining necessary information to make a determination on a prior

authorization request, whatever process is used. Therefore, the Department encourages insurers, HMOs,

administrators, and others to use the attached form.

Furthermore, the Department understands that no prior authorization is required by insurers for a patient with

a life-threatening condition; therefore, this form has no application in a life-threatening situation. If, during a prior

authorized surgical or other invasive procedure, a provider performs an additional related covered procedure due

to unforeseen medical necessity, the Department encourages insurers, HMOs, and TPAs not to deny coverage

solely for lack of prior approval, although the additional procedure was not included in the original prior approval.

Denials or partial denials should be explained to the requesting provider.

The Department is considering the adoption of an administrative rule that would require the use of a standard

prior authorization form for entities subject to the Department's jurisdiction. Voluntary use of the form following this

bulletin will provide practical experience and more valuable feedback during any rulemaking. Therefore, insurers

and others are urged to begin use of this form as soon as practicable.

Indiana Department of Insurance

______________________________________

Stephen W. Robertson, Commissioner

Prior Authorization Request Form for Health Care Services for Use in Indiana

Section I – Submission

Issuer Name

Phone

Fax

Date and Time Submitted

(

)

(

)

/ _______am/pm ET/CT

Section II – General Information

Review Type

Non Urgent

Urgent

Clinical reason for urgency

Request Type

Initial Request

Extension/Renewal/Amendment (Prev. Auth. #:

)

Section III – Patient Information

Name

Patient Contact Phone

DOB

Sex

Male

Female

(

)

Unknown

Subscriber Name (if different)

Member or Medicaid ID #

Group #

Date: Jan 20,2017 9:24:56PM EST

DIN: 20150304-IR-760150057NRA

Page 1

Department Of Insurance Prior Authorization Form In

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