Prior Authorization
A Prior Authorization (PA) is an authorization from MHS to provide services designated as requiring approval prior to treatment and/or payment. All procedures requiring authorization must be obtained by contacting MHS prior to rendering services. PA is required for certain services/procedures which are frequently over- and/or underutilized or services/procedures which are complex and may indicate a need for case management.
Check to see if a pre-authorization is necessary by using our online tool located on the sidebar. It's quick and easy. If an authorization is needed, you can access our Provider Portal to submit online.
Expand the links below to find out more information.
For imaging, outpatient surgeries and testing, requests for services may be obtained via:
- Phone: 1-877-647-4848
- Fax: 1-866-912-4245
- Online: Provider Portal
For DME, orthotics, prosthetics, home healthcare, and therapy (physical, occupational, speech), requests for services may be obtained via fax only: 1-866-912-4245.
Urgent (expedited) PA requests will be reviewed within 24 hours of receipt of a complete request.
- Non-urgent PA requests will be reviewed, and a determination will be issued within 48 hours of receipt of a complete request.
- Providers must respond to an adverse determination to correct, update, or appeal a decision within 48 hours after the decision is rendered.
- MHS will make all efforts to hold the peer-to-peer review within 48 hours of the request.
- MHS will provide acknowledgement of an appeal within 48 hours of the request.
Previously approved authorizations may be updated for changes in dates of service, servicing provider or CPT/HCPCS codes within 30 days of the original date of service. Authorization approval is for medical necessity only. If your claim subsequently denies, please contact MHS Provider Services at 1-877-647-4848 to determine the reason for the denial.
These timeframes do not include weekends or federal/state-approved holidays.
MHS remains committed to timely and clinically appropriate review of all prior authorization requests. We will continue to monitor and implement all applicable guidance issued by the Indiana Family and Social Services Administration (FSSA) and the Indiana Department of Insurance (IDOI) as it becomes available. All updates related to these changes, including revised guidelines and training materials, will be posted here on the MHS Provider website.
By logging on to the MHS Secure Provider Portal and completing an eligibility check, MHS will be notified of an ER visit by clicking on the Emergency Room Visit tab.
Contracted providers
Contracted providers requesting authorization for elective/routine services must obtain a PA at least two days prior to the date of service to ensure an authorization determination occurs prior to rendering a service. MHS does allow requests for authorization from contracted providers up to two days after the date of service, subject to the appropriate medical review.
Non-contracted providers
Non-contracted providers must obtain authorization two days prior to the date of service. Retroactive authorizations will not be granted except in the event of an emergent situation. If a provider is unable to request a PA at least two business days in advance due to the emergent nature of the member’s condition, a PA request must be initiated within two business days following the date of service/admission. MHS will make every effort to expedite the request. All emergency admissions/services require authorization within two business days of the admission/service.
Failure to obtain PA as previously described will result in claims payment denials for late notifications. Claim denials may result when a claim is denied due to a failure to obtain PA for services where PA is required.
Medical | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 6,318 | Medical Appeal Requests Received | 442 | |
Fully Approved | 4,965 | 78.58% | Overturned | 195 |
Adverse Determinations | 970 | 15.35% | Upheld | 219 |
Partial Approvals | 383 | 6.06% | Partial Approval | 28 |
Average time between submission and response | 1.25 DAYS |
| 11.18 Days | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 1,948 | Behavioral Appeal Requests Received | 245 | |
Fully Approved | 1,264 | 64.89% | Overturned | 61 |
Adverse Determinations | 121 | 6.21% | Upheld | 156 |
Partial Approvals | 563 | 28.90% | Partial Approval | 28 |
Average time between submission and response | 2.52 DAYS |
| 17.81 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 5.276 | Pharmacy Appeal Requests Received | 82 | |
Fully Approved | 2,640 | 50.04% | Overturned | 32 |
Adverse Determinations | 2,632 | 49.89% | Upheld | 50 |
Partial Approvals | 4 | 0.08% | Partial Approval | 0 |
Average time between submission and response | 0.3 DAYS |
| 12.58 DAYS | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
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Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
72148 | RADICULOPATHY LUMBAR REGION | Medical Necessity |
0345U | MAJ DEPRESS D/O RECURRENT MOD | Medical Necessity |
E1399 | AUTISTIC DISORDER | Medical Necessity |
81415 | AUTISTIC DISORDER | Medical Necessity |
E2510 | AUTISTIC DISORDER | Medical Necessity |
B4160 | FAILURE TO THRIVE CHILD | Medical Necessity |
97530 | AUTISTIC DISORDER | Medical Necessity |
78451 | CHEST PAIN UNSPECIFIED | Medical Necessity |
99600 | AUTISTIC DISORDER | Medical Necessity |
72141 | RADICULOPATHY CERVICAL REGION | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
97151 | AUTISTIC DISORDER | Medical Necessity |
97155 | AUTISTIC DISORDER | Medical Necessity |
97153 | AUTISTIC DISORDER | Medical Necessity |
97156 | AUTISTIC DISORDER | Medical Necessity |
H0015 | CANNABIS DEPENDENCE UNCOMPLICATED | Medical Necessity |
H0010 | OTH STIMULANT DEPEND UNCOMPLICATED | Medical Necessity |
S9480 | GENERALIZED ANXIETY DISORDER | Medical Necessity |
96130 | POST-TRAUMATIC STRESS DISORDER UNS | Medical Necessity |
90837 | ADHD COMBINED TYPE | Medical Necessity |
H0035 | ALCOHOL DEPENDENCE UNCOMPLICATED | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J0585 | CRAMP AND SPASM | Medical Necessity |
J7318 | BILATERAL PRIM OSTEOARTHRITIS KNEE | Medical Necessity |
J0897 | AGE-REL OSTEOPOR W/O CURR PATH FX | Medical Necessity |
J0185 | MALIG NEO UNS PART RT BRONCHU/LUNG | Medical Necessity |
J2506 | MAL NEOPLASM UP LOBE RT BRONCH/LUNG | Medical Necessity |
J1437 | IRON DEFICIENCY | Medical Necessity |
J7999 | OTHER CHRONIC PAIN | Medical Necessity |
Q5119 | OTH SPEC D/O INVOLV IMMUNE MECH NEC | Medical Necessity |
Q5107 | MALIGNANT NEOPLASM OF APPENDIX | Medical Necessity |
J7328 | UNI PRIM OSTEOARTHRITIS RT KNEE | Medical Necessity |
Medical | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 8,925 | Medical Appeal Requests Received | 420 | |
Fully Approved | 7,353 | 72.39% | Overturned | 183 |
Adverse Determinations | 953 | 10.68% | Upheld | 226 |
Partial Approvals | 619 | 6.94% | Partial Approval | 11 |
Average time between submission and response | 1.66 DAYS |
| 10.17 DAYS | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 2,609 | Behavioral Appeal Requests Received | 260 | |
Fully Approved | 1,688 | 64.70% | Overturned | 74 |
Adverse Determinations | 112 | 4.29% | Upheld | 160 |
Partial Approvals | 809 | 31.01% | Partial Approval | 26 |
Average time between submission and response | 2.05 DAYS |
| 18.21 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 4,372 | Pharmacy Appeal Requests Received | 80 | |
Fully Approved | 2,545 | 58.21% | Overturned | 42 |
Adverse Determinations | 2,545 | 58.21% | Upheld | 38 |
Partial Approvals | 4 | 0.09% | Partial Approval | 0 |
Average time between submission and response | 0.31 Days |
| 12.7 Days | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
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Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
D8080 | PART LOSS TEETH UNS CAUSE UNS CLASS | Medical Necessity |
0345U | MAJ DEPRESS D/O RECURRENT MOD | Medical Necessity |
B4161 | GERD WITHOUT ESOPHAGITIS | Medical Necessity |
B4160 | FAILURE TO THRIVE CHILD | Medical Necessity |
E2510 | AUTISTIC DISORDER | Medical Necessity |
92507 | DEVELPMENTL D/O SPEECH LANGUAGE UNS | Medical Necessity |
73720 | PAIN IN LEFT KNEE | Medical Necessity |
70450 | HEADACHE UNSPECIFIED | Medical Necessity |
81415 | DEVELPMENTL D/O SPEECH LANGUAGE UNS | Medical Necessity |
D8020 | PART LOSS TEETH UNS CAUSE UNS CLASS | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
97151 | AUTISTIC DISORDER | Medical Necessity |
97156 | AUTISTIC DISORDER | Medical Necessity |
97155 | AUTISTIC DISORDER | Medical Necessity |
97153 | AUTISTIC DISORDER | Medical Necessity |
90837 | ADJUSTMENT DISORDER WITH ANXIETY | Medical Necessity |
97152 | AUTISTIC DISORDER | Medical Necessity |
97157 | AUTISTIC DISORDER | Medical Necessity |
H0015 | CANNABIS DEPENDENCE UNCOMPLICATED | Medical Necessity |
96130 | ADHD COMBINED TYPE | Medical Necessity |
90792 | MENTAL DISORDER NOS | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J3490 | OBESITY CLASS 3 | Medical Necessity |
J9312 | NEPHROTIC SYND W/UNS MORPH CHANGES | Medical Necessity |
J0585 | CHR MIGR W/O AURA NOT INTRCT W/O SM | Medical Necessity |
J1437 | IRON DEFICIENCY ANEMIA UNSPECIFIED | Medical Necessity |
J1439 | IRON DEFICIENCY | Medical Necessity |
J1745 | ULCERATIVE COLITIS UNS RECTAL BLEED | Medical Necessity |
J2357 | SEVERE PERSIST ASTHMA UNCOMPLICATED | Medical Necessity |
Q0138 | IRON DEFICIENCY ANEMIA UNSPECIFIED | Medical Necessity |
Q5126 | MALIGNANT NEOPLASM OF BRAIN STEM | Medical Necessity |
MHS Prior Authorization Statistics for 2026
2026 calendar year data per SEA 480* - Healthy Indiana Plan (HIP)
*Quarter 3: July 1, 2026 – September 30, 2026
- Last Updated: 10/23/2026
- Next Scheduled Update: Q4 2026
Medical | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 22,113 | Medical Appeal Requests Received | 843 | |
Fully Approved | 16,886 | 76.36% | Overturned | 320 |
Adverse Determinations | 4,024 | 18.24% | Upheld | 496 |
Partial Approvals | 1,203 | 5.44% | Partial Approval | 27 |
Average time between submission and response | 1.25 Days |
| 9.19 Days | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 4,563 | Behavioral Appeal Requests Received | 168 | |
Fully Approved | 3,419 | 74.93% | Overturned | 21 |
Adverse Determinations | 502 | 11% | Upheld | 139 |
Partial Approvals | 642 | 14.07% | Partial Approval | 8 |
Average time between submission and response | 4.21 Days |
| 16.51 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 23,354 | Pharmacy Appeal Requests Received | 311 | |
Fully Approved | 10,045 | 43.01% | Overturned | 95 |
Adverse Determinations | 13,290 | 56.91% | Upheld | 216 |
Partial Approvals | 19 | 0.08% | Partial Approval | 0 |
Average time between submission and response | 0.3 Days |
| 12.51 Days | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
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Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
72148 | RADICULOPATHY LUMBAR REGION | Medical Necessity |
0345U | MAJ DEPRESS D/O RECURRENT MOD | Medical Necessity |
72141 | RADICULOPATHY CERVICAL REGION | Medical Necessity |
G0483 | ENC THERAPEUTC DRUG LEVL MONITORING | Medical Necessity |
78451 | CHEST PAIN UNSPECIFIED | Medical Necessity |
93307 | PALPITATIONS | Medical Necessity |
74176 | UNSPECIFIED ABDOMINAL PAIN | Medical Necessity |
73221 | PAIN IN RIGHT SHOULDER | Medical Necessity |
64635 | SPONDYLS W/O MYELO-/RADICULOP LUMB | Medical Necessity |
73720 | PAIN IN LEFT KNEE | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
H0015 | ALCOHOL DEPENDENCE UNCOMPLICATED | Medical Necessity |
H0010 | ALCOHOL DEPENDENCE UNCOMPLICATED | Medical Necessity |
90837 | GENERALIZED ANXIETY DISORDER | Medical Necessity |
H0035 | ALCOHOL DEPENDENCE UNCOMPLICATED | Medical Necessity |
90791 | OPIOID DEPENDENCE UNCOMPLICATED | Medical Necessity |
S9480 | MAJ DEPRESS D/O RECURR PART REMISS | Medical Necessity |
H2034 | OPIOID DEPENDENCE UNCOMPLICATED | Medical Necessity |
H2001 | SYNCOPE AND COLLAPSE | Medical Necessity |
96130 | ADJUST D/O W/MIXED DISTURB EMOTIONS | Medical Necessity |
99215 | MAJ DEPRESS D/O RECURRENT MOD | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J0897 | AGE-REL OSTEOPOR W/O CURR PATH FX | Medical Necessity |
J0585 | CHR MIGR W/O AURA NOT INTRCT W/O SM | Medical Necessity |
J7327 | UNI PRIM OSTEOARTHRITIS RT KNEE | Medical Necessity |
J7325 | BILATERAL PRIM OSTEOARTHRITIS KNEE | Medical Necessity |
J1437 | IRON DEFIC ANEMIA SEC BLD LOSS CHRN | Medical Necessity |
J7324 | BILATERAL PRIM OSTEOARTHRITIS KNEE | Medical Necessity |
J7323 | UNI PRIM OSTEOARTHRITIS LT KNEE | Medical Necessity |
J7318 | UNI PRIM OSTEOARTHRITIS RT KNEE | Medical Necessity |
J2357 | SEVERE PERSIST ASTHMA UNCOMPLICATED | Medical Necessity |
Q0138 | IRON DEFIC ANEMIA SEC BLD LOSS CHRN | Medical Necessity |