CurrentOptumPolicy N/A

Prior Authorization Request Form

Administrative prior authorization request form used to request authorization for services (e.g., DME, home health, therapies) and indicates which entity must authorize the service; applies to providers submitting authorization requests for IHCP members.

Policy Summary

PayerOptum

PolicyPrior Authorization Request Form

Policy CodePolicy N/A

Change TypeMinor / Informational

Effective Date

Next Review Date

Key ActionSelect the radio button for the entity that must authorize the service and include medical documentation with a qualified practitioner signature for medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11document chunks/pages parsed

multipleauthorization entities/options listed

requiredICD diagnostic code required

requiredmedical documentation required

fieldsinformation sections

Prior Authorization Coverage Criteria

Prior authorization submission criteria

Covered when ALL of the following form-level submission requirements are met:

ALL of the following

ICD diagnostic code is required (enter at least Dx1; Dx2 and Dx3 fields available)
Medical documentation must be included to support medical necessity
Signature of a qualified practitioner and date are required
Select the appropriate assignment category for the requested service (e.g., DME; Purchased; Rented; Home Health; Hospice; Inpatient; Observation; Office Visit; Occupational Therapy; Outpatient)

Policy Summary

PayerOptum

PolicyPrior Authorization Request Form

Policy CodePolicy N/A

Change TypeMinor / Informational

Effective Date

Next Review Date

Key ActionSelect the radio button for the entity that must authorize the service and include medical documentation with a qualified practitioner signature for medical necessity review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Submission Requirements

Prior Authorization

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-for-service). Use the Prior Authorization Request Form and select the appropriate payer/managed-care entity and provide the contact details (phone and fax) for that entity when listed. Examples of entities and contacts include: Acentra Health (P: 866-725-9991, F: 800-261-2774); Anthem Hoosier Healthwise (P: 866-408-6132, F: 866-406-2803); CareSource Hoosier Healthwise (P: 844-607-2831, F: 844-432-8924); MDwise Hoosier Healthwise (P: 888-961-3100, F: 888-465-5581); MHS Hoosier Healthwise (P: 877-647-4848, F: 866-912-4245); Anthem HIP (P: 844-533-1995, F: 866-406-2803); CareSource HIP (P: 844-607-2831, F: 844-432-8924); MDwise HIP (P: 888-961-3100, F: 866-613-1642); Anthem Hoosier Care Connect (P: 844-284-1798, F: 866-406-2803); UnitedHealthcare (P: 877-610-9785, F: 844-897-6514); Anthem PathWays (P: 844-284-1798, F: 877-410-0623); 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 on the form.

Documentation Required

Submission Requirements

Your request MUST include medical documentation to be reviewed for medical necessity. The form must include the signature of a qualified practitioner and the date. See the IHCP Quick Reference Guide for information about where to mail this form.

Include complete medical records and documentation supporting medical necessity.
Ensure the Qualified Practitioner's signature and date are present on the form.
Follow mailing instructions in the IHCP Quick Reference Guide.

Definitions and Administrative Categories

inv-06: managed care authorization routing — guidance to check the member's plan unless carved out; routing instructions.

Routing guidanceFor managed care, check the member's plan to determine which entity must authorize the service; if the service is carved out (delivered as fee-for-service), select the Fee-for-Service option.

Select authorization entityUse the form radio buttons to select the entity that must authorize the service (examples in form include Fee-for-Service, Acentra Health, Hoosier, Anthem Hoosier Healthwise).

Contact details on formManaged care plan options on the form include phone/fax contacts for specific plans (phone/fax shown next to plan selections).

Carve-out handlingIf carved out, treat authorization as Fee-for-Service rather than the member's managed care plan.

inv-07: assignment category — list of assignment categories (DME, Purchased, Rented, Home Health, Hospice, Inpatient, Observation, Office Visit, Occupational Therapy, etc.).

Primary assignment categoriesDME; Purchased; Rented; Home Health; Hospice; Inpatient; Observation; Office Visit; Occupational Therapy; Outpatient

UsageProviders must check the requested assignment category box on the form to indicate the type of service or item being requested.

Diagnosis requirement linkICD diagnostic code fields (Dx1, Dx2, Dx3) are present on the form and should accompany the selected assignment category.

Procedure/Service Codes	Procedure/Service Codes field present on form
Modifiers	Modifiers fields present on form
Place of Service (POS)	Place of Service (POS) field present on form
Units	Units field present on form
Dollars	Dollars field present on form

OpenPayer

Prior Authorization Request Form

Prior Authorization Coverage Criteria

Diagnosis and Procedure Coding

Provider Actions and Submission Requirements

Definitions and Administrative Categories

Dx1	ICD diagnostic code is required (Dx1)
Dx2	ICD diagnostic code is required (Dx2)
Dx3	ICD diagnostic code is required (Dx3)