Indiana Prior Authorization Law

What is a prior authorization denial?

A prior authorization denial happens before treatment, medication, surgery, imaging, or another service is approved. If your doctor requested approval and the insurer said no, this is usually a pre-service denial—not a claim denial after care was already provided.

Indiana has a specific health care service prior authorization law. It does not apply to every plan (self-funded ERISA and some federal programs follow different rules). Confirm plan type first: Indiana: Start Here.

Indiana prior authorization law

For plans subject to Indiana's law, prior authorization requirements and written clinical criteria must be made readily accessible online. Insurers and utilization review entities generally must give advance notice before new or amended prior authorization requirements take effect. Indiana also requires reporting on approvals, denials, denial reasons, appeals, and appeal outcomes. Indiana Code § 27-1-37.5-19

Response deadlines for covered plans (Indiana Code § 27-1-37.5-23):

• Urgent requests: generally answered within 24 hours
• Non-urgent health care services or prescription drugs: generally within 48 hours, excluding weekends and legal holidays

If the request is denied, the response must include specific reasons and suggested alternatives.

Peer-to-peer review: after an adverse prior authorization determination, the treating provider may request a peer-to-peer review. The plan must offer the process and make every effort to complete it within seven business days after the request, when needed information has been received. Indiana Code § 27-1-37.5-17

Insurer PA lookup tools

Use these starting points to see whether a service may require prior authorization and how to submit or appeal. Always match the tool to the exact plan on the member ID card—not every link applies to every product.

For 2026 individual Marketplace coverage, Indiana lists Anthem, CareSource, Cigna, Coordinated Care Corporation (Ambetter), and UnitedHealthcare as carriers (in.gov — open enrollment fact sheet).

• Anthem BCBS Indiana: individual and commercial PA code lists, Indiana lookup tools, medical policies, Indiana Medicaid PA resources — anthem.com — prior authorization
• Ambetter / Coordinated Care (MHS Indiana): Pre-Auth Check, provider toolkit, member grievance and appeal forms — ambetterhealth.com — pre-auth check
• CareSource Indiana: Marketplace referrals and PA, 2026 Marketplace PA list, appeal information — caresource.com — referrals and prior authorization
• Cigna: precertification, CignaForHCP portal, eviCore for some services, appeals — cigna.com — precertification
• UnitedHealthcare: advance notification and PA requirements, provider verification, member appeal forms — uhcprovider.com — prior auth
• Aetna: member complaints and appeals, PA dispute/review, expedited and external review — aetna.com — complaints and appeals
• Humana Healthy Horizons (Indiana Medicaid / PathWays): PA search tools and Medicaid grievance resources — humana.com — Indiana Medicaid prior authorization
• MHS Indiana Medicaid: PA page and lookup tool — mhsindiana.com — prior authorization
• IU Health Plans / PHPNI: use the denial letter, EOB, member portal, and IDOI-filed grievance procedures for plan-specific steps — iuhealthplans.org

Indiana Medicaid

Fee-for-service (IHCP): Indiana Medicaid requires prior authorization for certain covered services to document medical necessity. Guidance is on the Indiana Health Coverage Programs site — in.gov — Medicaid prior authorization.

Managed care (2026):programs such as HIP, Hoosier Healthwise, Hoosier Care Connect, and PathWays generally use the member's MCO for PA and appeals. As of 2026, participating plans include Anthem, CareSource, Humana, MHS, and UnitedHealthcare. FSSA announced MDwise is no longer a Medicaid health plan option after January 1, 2026—verify the active plan on the member's card (in.gov — Medicaid health plans).

When PA is denied or missing

Prior authorization was never obtained

If the denial says prior authorization was missing, you may still have options. Ask the insurer and provider who was supposed to request it, get the denial reason in writing, and ask whether a corrected submission, retroactive review, peer-to-peer, or appeal is still possible.

Prior authorization was denied

If PA was requested but denied, get the exact clinical rule, policy, or medical necessity criteria the insurer used. Ask the treating clinician to appeal with supporting records. Check the denial letter for internal appeal deadlines—see Indiana internal appeals & grievances. If internal review fails, Indiana external review may apply for certain denials.

Prescription drugs

Missing prior authorization can block the pharmacy from filling the medication. Drug denials may need a formulary exception, step-therapy exception, or medication appeal from the prescriber—not only a claim fix.

Advocate checklist:

1. Confirm plan type and whether Indiana's PA statute applies.
2. Get the denial reason and criteria in writing.
3. Ask whether peer-to-peer is available and who schedules it.
4. Have the clinician appeal with records tied to the insurer's policy.
5. Save proof of submission and watch urgent vs. standard deadlines.

Emergency services

Emergency services needed to screen or stabilize a covered person are treated differently from routine prior authorization. Medical necessity for emergency care cannot be restricted more heavily solely because the provider was out-of-network (Indiana Code § 27-1-37.5-24). Federal No Surprises Act protections may also apply.

If the case is urgent but not a true emergency, ask for expedited prior authorization and appeals under the 24-hour and 72-hour rules described above and in expedited appeals on the Appeals Roadmap.