Referrals And Prior Authorizations In Indiana
For some Medicaid services, you’ll need a referral from your primary medical provider (PMP) before getting care.
When To Get A Referral In Indiana
A referral is when your primary medical provider (PMP) sends you to another provider for care. This care is often from a specialist. Your PMP may send you to a specialist for special care or treatment. Your PMP can:
- Help choose a specialist to give you the care you need.
- Help you set the day and time for the office visit with a specialist.
- Ask Anthem is if you can get services from a specialist. Your PMP knows when to ask for a prior authorization. (See below.)
Some types of services are known as self-referral services. That means you can get these services without a referral from your PMP. You can see any Indiana Health Coverage Programs (IHCP) doctor for many of these services. See your member handbook for a list of these service
You May Need Prior Authorization For A Service
Some services require a prior authorization, or OK, from Anthem. Your PMP will ask Anthem to make sure they’re offered. If they are, both Anthem and your PMP or specialist agree the services are medically necessary.
Getting a prior authorization will take no more than five business days or, if urgent, no more than 48 hours.
These are types of services, if offered in your health plan, that need prior authorization:
- Air ambulance
- Certain behavioral health services
- Biofeedback
- Drug injections
- Certain dental services
- Some equipment
- Genetic testing
- Home health and hospice care
- Hyperbaric oxygen therapy
- Infusion therapy and chemotherapy
- Inpatient hospital services
- Certain laboratory tests
- Services not in your plan
- Referrals to specialists
- Radiology services
- Select outpatient surgeries/procedures
- Sensory integration therapy
- Transplant services
- Certain vision services
Your PMP will know which services need prior authorization. We may not approve payment for a service you or your doctor asks for. If your case doesn’t meet the rules for medically needed, we’ll send you a letter. The letter will tell you we could not authorize the service and why. The letter will also let you know how to appeal our decision if you disagree with it. For more help, please call Member Services at 866-408-6131 (TTY 711) (Hoosier Healthwise, Healthy Indiana Plan); 844-284-1797 (TTY 711) (Hoosier Care Connect), 833-412-4405 (TTY 711) (PathWays for Aging).
Have questions?
Check your member handbook or live chat with a representative through the online portal or the Sydney Health app.
Page last update: 12/16/2024