Indiana IN

Indiana Health Coverage Programs (IHCP) PA is split by delivery system. FFS: decisions on medical necessity per federal/state code + IHCP-approved internal criteria, reviewed case-by-case by TWO vendors -- Optum Rx (ALL FFS pharmacy PA, statewide carve-out; criteria/forms at inm.pharmacy.optum.com) and Acentra Health (ALL FFS nonpharmacy PA, submitted via the Atrezzo Provider Portal at atrezzo.acentra.com, or fax/mail/phone using PA request forms). WHETHER a code requires PA in FFS lives in the Outpatient/Professional Fee Schedules (PA flag column), NOT a standalone code list. PA POLICY lives in the IHCP Provider Reference Modules (the Prior Authorization module = canonical narrative). Service-specific PA criteria are expressed as CHECKLISTS/forms (ABA, Therapy, SUD, Dental). Managed care: the four MCE programs (Hoosier Healthwise, HIP, Hoosier Care Connect, PathWays for Aging) are FULLY DELEGATED -- each MCE owns its code-requires-PA list, criteria, processes, and CMS-0057-F metrics; providers contact the enrolled MCE. Some services are carved OUT of managed care to FFS for all members (see Member Eligibility & Benefit Coverage module). Authority = FSSA/OMPP sets policy via reference modules; Acentra+Optum Rx operate FFS PA; MCEs operate managed-care PA; Gainwell runs CoreMMIS/IHCP portal. CMS-0057-F: IN publishes FFS PA metrics (Acentra 2025 report, xlsx); MCE metrics are per-plan. URL DECAY: state_meta pa_index (business-transactions/prior-authorization) now 404 -- site moved PA home to clinical-services/prior-authorization. Old provider_manual page (business-transactions/provider-references) also 404 (PA module PDF already re-pinned in finding 620).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

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## 1. How IN requires PA Indiana Health Coverage Programs (IHCP / Indiana Medicaid) structure prior authorization (PA) around specific criteria and forms for various services. For non-pharmacy services, providers must confirm medical necessity via the IHCP Professional or Outpatient Fee Schedule, as outlined in "Best Practices for Nonpharmacy Prior Authorization" (effective January 2024), which emphasizes medical-necessity documentation and ICD codes. For pharmacy services, Indiana uses a hybrid model where all FFS pharmacy PA is handled by Optum Rx (`inm.pharmacy.optum.com`). For therapy services, providers must submit documentation including primary diagnosis, service codes, requesting/rendering provider details, and signatures (Therapy-PA-Checklist.pdf, rev. Nov. 9, 2022). ABA services require a completed screening/diagnostic evaluation meeting ASD criteria, signed by a qualified practitioner; treatment plans must include targeted behaviors, psychological/medical concerns, and family issues, with measurable baselines and timelines (ihcp-aba-prior-auth-checklist.pdf, effective July 2018). Residential/Inpatient Substance Use Disorder (SUD) treatment requires an ASAM 3.1 or 3.5 designation, without step-therapy (SUD-PA-form.pdf, effective May 2026). Dental treatments require documentation of dental and medical history (dental-pa-form.pdf, effective August 2022). ## 2. How IN publishes and reports PA Indiana Medicaid publishes its PA guidance through multiple documents and portals. The primary general document is the Provider Manual / prior-authorization module (Library Reference PROMOD00012, version 7.2, published Nov. 20, 2025), which references IHCP Bulletins (e.g., BT202496, BT202434) for specific PA requirements. Service-specific criteria are detailed in checklists and forms (e.g., Therapy-PA-Checklist.pdf, ihcp-aba-prior-auth-checklist.pdf). For non-pharmacy services, Acentra/Atrezzo handles decisions on medical necessity per federal/state code and IHCP-approved internal criteria. Pharmacy PA is managed through Optum Rx's portal (`inm.pharmacy.optum.com`). ## 3. IN's CMS-0057-F and PA-reform compliance posture Indiana Medicaid does not explicitly detail its CMS-0057-F compliance in the source documents. The state uses a hybrid carve-out model for pharmacy services (centralizing FFS pharmacy PA through Optum Rx), and a split structure with FFS dual-vendor models (Acentra/Atrezzo nonpharmacy + Optum Rx pharmacy) plus MCE-delegated managed care — a structure that may interact with federal reforms but is not documented as explicit compliance. Indiana is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Indiana.) No WISeR participation should be inferred for IN. ## 4. How IN runs its own program Indiana Medicaid's program model splits between FFS and managed care, with specific carve-outs for pharmacy services. Non-pharmacy PA decisions are reviewed by Acentra/Atrezzo; all FFS pharmacy PA is handled through Optum Rx. The MCO procurement cycle is structured around a 4-year base contract with two 1-year options (per IC 12-15-30-4). Contracts for HHW_HIP, HCC, and PathWays carry extensions through 2026-2028 (exact last-award/next-due dates not specified in the source documents). The fiscal-agent history shows transitions from ACS-Inc to Conduent/Gainwell. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Hybrid Carve-out Model**: All FFS pharmacy PA managed by Optum Rx. - **Service-Specific Guidelines**: Detailed checklists/forms per service. - **Vendor Management**: Tracks vendor transitions and service continuity. ### What's Missing/Uncertain: - **CMS-0057-F Compliance**: No explicit documentation in the corpus. - **Foster Care Program Details**: Unspecified in the findings. - **1115 Waiver Details**: The specific 1115 waiver is unnamed in the source documents. - **Provider Manual URL Decay**: The provider-manual URL has been rediscovered; currency of all internal links unclear. - **MCO Procurement Dates**: Exact last-award and next-due dates not provided.

Last award: ?. Next due: 2028-12-31 (target new-contract effective date 2029-01-01). Contracts extended through: {'HHW_HIP': '2026-12-31 (original term); option years through 2028-12-31', 'HCC': '2028-12-31 (extended)', 'PathWays': '2028-06-30'}.