Get In Prior Authorization Request Form 2018-2025

This guide provides comprehensive instructions for completing the Indiana Health Coverage Programs Prior Authorization Request Form online. By following these steps, users can efficiently and accurately submit their requests.

Follow the steps to complete your form efficiently

1. Click ‘Get Form’ button to access the Prior Authorization Request Form in the editor.
2. Begin by filling out the patient information section, which includes the patient's IHCP Member ID, date of birth, name, and address. Ensure accuracy to avoid processing delays.
3. Next, provide the requesting provider information. Enter the provider's NPI/Provider ID, name, address, and contact details. This establishes who is requesting the authorization.
4. Fill in the rendering provider information. This includes the rendering provider's NPI/Provider ID, name, and contact details, which are necessary for verification.
5. Complete the ordering, prescribing, or referring (OPR) provider information section. Input the OPR physician's NPI and phone number to ensure the relevant medical professional is documented.
6. Provide the medical diagnosis using ICD diagnostic codes. Include Dx1, Dx2, and Dx3 as applicable, as these codes are crucial for justification of the request.
7. Indicate the procedure or service codes, including any modifiers and how many units are necessary for the service, as well as the expected dates of service.
8. Select the requested assignment category that corresponds to the service being requested, such as DME, inpatient, or outpatient, among others.
9. Ensure to attach any required medical documentation to substantiate the medical necessity of the request.
10. Finally, enter the name, phone number, and fax number of the preparer. The qualified practitioner should then sign and date the form.
11. After filling out the form, save your changes. You may download, print, or share the completed form as needed for your records or submission.

Take action now — complete the IN Prior Authorization Request Form online for your health coverage needs.