Physician certification of medical necessity for home oxygen under Indiana Medicaid.
- Completed by
- Ordering physician/practitioner
- Issued by
- Indiana Family and Social Services Administration (IHCP)
- Format
- Language
- English
Indiana IHCP Prior Authorization Request Form
Indiana Health Coverage Programs uses one prior authorization request form for fee-for-service and every managed care plan in Hoosier Healthwise, the Healthy Indiana Plan, Hoosier Care Connect and Indiana PathWays for Aging. Providers meet it when a nonpharmacy service, such as DME, home health, therapy, hospice, transportation or an inpatient stay, needs approval. The provider selects the entity that must authorize the service, lists codes and units, and attaches medical documentation.
Who completes it
The requesting provider's office completes the form, including the member's primary medical provider, the rendering and the ordering, prescribing or referring (OPR) providers, ICD diagnosis codes and service lines. A qualified practitioner signs page 2.
Submitting and payment
- How to submit it
- Fax it to the entity selected on the form, whose phone and fax numbers are printed beside each choice, or submit through the Acentra Health Atrezzo portal or the plan's portal. Mailing addresses are in the IHCP Quick Reference Guide.
Good to know
- For a managed care member, select the member's plan unless the service is carved out and delivered as fee-for-service, in which case select Acentra Health.
- Every request must include medical documentation, because the service is reviewed for medical necessity.
- Pick the assignment category that fits: DME purchased or rented, home health, hospice, inpatient, observation, outpatient, physical, occupational or speech therapy, office visit, transportation or other.
- Version 10.1 (May 2026) is current. Changes to an approved authorization use the IHCP PA Revision Request Form, and residential or inpatient SUD treatment has its own request form.
Get the official form
Download the current version from the source each time; forms change without notice.
Indiana Health Coverage Programs Prior Authorization Request Form
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Which Indiana Medicaid plans accept the IHCP Prior Authorization Request Form?
All of them. The form lists fee-for-service through Acentra Health and each managed care entity: Anthem, CareSource and MHS in Hoosier Healthwise and HIP; Anthem, MHS and UnitedHealthcare in Hoosier Care Connect; and Anthem, Humana and UnitedHealthcare in Indiana PathWays for Aging.
Who signs the IHCP prior authorization form?
Page 2 has a line for the signature of a qualified practitioner, with the date. The preparer's name, phone and fax are recorded separately on page 1, so the person preparing the request and the practitioner who signs it can be different people.
Is the IHCP Prior Authorization Request Form used for drugs?
No. It is the nonpharmacy prior authorization request. Its assignment categories cover DME, home health, hospice, inpatient and outpatient services, observation, therapies, office visits and transportation, and each request must include medical documentation for the medical necessity review.