Department Of Insurance Prior Authorization Form In Page 3


Indiana Register
The Indiana Department of Insurance encourages all insurers, HMOs, administrators, and others to accept the
Standardized Prior Authorization Request Form for Health Care Services for Use in Indiana if the plan requires
prior authorization of a health care service.
Intended use: When an issuer requires prior authorization of a health care service, use this form to request the
authorization by mail. An issuer also may provide on its website an electronic version of this form that can be
completd [sic] and submitted to the issuer electronically via the issuer's portal.
Do not use this form: 1) to request an appeal, 2) to confirm eligibility, 3) to verify coverage, 4) to ask whether a
service requires prior authorization, 5) to request prior authorization of a prescription drug, or 6) to request a
referral to an out-of-network physician, facility or other health care provider.
Additional information and instructions:
Section I. An issuer may have already prepopulated its contact information on the copy of this form posted on its
Section II. Urgent reviews: Request an urgent review for a patient who is currently hospitalized, or to authorize
treatment following stabilization of an emergency condition. You also may request an urgent review to authorize
treatment of an acute injury or illness, if the provider determines that the condition is severe or painful enough to
warrant an expedited or urgent review, to prevent a serious deterioration of the patient's condition or health.
Section IV.
• If the Requesting Provider or Facility also will be the Service Provider or Facility, enter "Same."
• If the requesting provider's signature is required, you may not use a signature stamp.
• If the issuer's plan requires the patient to have a primary care provider (PCP), enter the PCP's name and
phone number. If the requesting provider is the patient's PCP, enter "Same."
Section VI.
• Give a brief narrative of medical necessity in this space, or in an attached statement.
• Attach supporting clinical documentation (medical records, progress notes, lab reports, radiology studies,
etc.), if needed.
Section VII.
• Give a brief narrative of why the request was denied or partially denied.
Note: Some issuers may require more information or additional forms to process your request. If you think an
additional form may be needed, please check the issuer's website before transmitting your request.
If the requesting provider wants to be called directly about missing information that the issuer must have to
process this request, and the provider's contact information is not the contact information listed in Section IV,
enter the provider's contact information in the space given at the bottom of the request form. This call is intended
only to ensure that the issuer receives the information it needs to review the request. It is not a peer-to-peer
discussion afforded by a utilization review agent (URA) before issuing an adverse determination, as required by
28 TAC §19.1710.
Posted: 03/04/2015 by Legislative Services Agency
version of this document.
Date: Jan 20,2017 9:24:56PM EST
DIN: 20150304-IR-760150057NRA
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