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 | 11,294 | Medical Appeal Requests Received | 458 | |
Fully Approved | 8,773 | 78% | Overturned | 175 |
Adverse Determinations | 2,292 | 20% | Upheld | 235 |
Partial Approvals | 89 | 0.7% | Partial Approval | 14 |
Average time between submission and response | 2.23 Days *Including RFI |
| 13 Days | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 5,035 | Behavioral Appeal Requests Received | 183 | |
Fully Approved | 3,765 | 75% | Overturned | 25 |
Adverse Determinations | 66 | 1.3% | Upheld | 123 |
Partial Approvals | 828 | 16% | Partial Approval | 35 |
Average time between submission and response | 3.06 Days *Including RFI |
| 17 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 7,488 | Pharmacy Appeal Requests Received | 102 | |
Fully Approved | 4,050 | 54.1% | Overturned | 36 |
Adverse Determinations | 3,438 | 45.9% | Upheld | 62 |
Partial Approvals | 0 | 0 | Partial Approval | 0 |
Average time between submission and response | 0.48 Days *Including RFI |
| 15 Days | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
|
|
|
|
|
|
|
|
|
|
|
|
Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
97116 | Low Back Pain | Medical Necessity |
92507 | Autistic Disorder | Medical Necessity |
93307 | Chest Pain | Medical Necessity |
70551 | Headache | Medical Necessity |
71250 | Pulmonary Nodule | Medical Necessity |
B4160 | Failure to Thrive | Medical Necessity |
99600 | Autistic Disorder | Medical Necessity |
74176 | Abdominal Pain | Medical Necessity |
72148 | Radiculopathy, Lumbar Region | Medical Necessity |
E1390 | COPD | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
H0010 | Drug/Alcohol Dependence | Medical Necessity |
97151 | Autistic Disorder | Medical Necessity |
96130 | Autistic Disorder | Medical Necessity |
97155 | Autistic Disorder | Medical Necessity |
97153 | Autistic Disorder | Medical Necessity |
97156 | Autistic Disorder | Medical Necessity |
H0015 | Stimulant Dependence | Medical Necessity |
90837 | Major Depressive Disorder | Medical Necessity |
97152 | Autistic Disorder | Medical Necessity |
H2034 | Alcohol Dependence | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J1439 | Iron Deficiency Anemia Unspecified | Medical Necessity |
J1628 | Ulcerative Chronic Pancolitis w/o Complications | Medical Necessity |
J9370 | Illness Unspecified | Medical Necessity |
J1745 | Crohns Disease | Medical Necessity |
J1459 | Acute Lymphoblastic Leukemia in Remission | Medical Necessity |
J2916 | Anemia in Neoplastic Disease | Medical Necessity |
J2506 | Immunodeficiency Due to Drugs | Medical Necessity |
J1628 | Other Fecal Abnormalities | Medical Necessity |
J9000 | Malignant Neoplasm RT Kidney Except Renal Pelvis | Medical Necessity |
J1437 | Abnormal Level of Blood Mineral | Medical Necessity |
MHS Prior Authorization Statistics for 2025
2025 calendar year data per SEA 480* - Hoosier Healthwise (HHW)
*July 1, 2025 – November 30, 2025
Medical | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 12,591 | Medical Appeal Requests Received | 307 | |
Fully Approved | 10,346 | 82% | Overturned | 109 |
Adverse Determinations | 1,371 | 11% | Upheld | 160 |
Partial Approvals | 818 | 6% | Partial Approval | 4 |
Average time between submission and response | 1.87 days *Including RFI |
| 18 Days | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 5,696 | Behavioral Appeal Requests Received | 177 | |
Fully Approved | 4,427 | 78% | Overturned | 30 |
Adverse Determinations | 46 | 0.8% | Upheld | 116 |
Partial Approvals | 845 | 15% | Partial Approval | 31 |
Average time between submission and response | 2.78 days *Including RFI |
| 17 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 4,454 | Pharmacy Appeal Requests Received | 54 | |
Fully Approved | 2,591 | 58.2% | Overturned | 22 |
Adverse Determinations | 1,863 | 41.8% | Upheld | 29 |
Partial Approvals | 0 | 0 | Partial Approval | 0 |
Average time between submission and response | 0.42 Days *Including RFI |
| 16 Days | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
|
|
|
|
|
|
|
|
|
|
|
|
Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
92507 | Development Disorder, Speech | Medical Necessity |
97116 | Pain in Right Knee | Medical Necessity |
97533 | Autistic Disorder | Medical Necessity |
93307 | Palpitations | Medical Necessity |
70551 | Headache, Unspecified | Medical Necessity |
73720 | Pain in Right Knee | Medical Necessity |
72148 | Low Back Pain | Medical Necessity |
0345U | ADHD | Medical Necessity |
74176 | Abdominal Pain | Medical Necessity |
73331 | Pain in Left Shoulder | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
96130 | Major Depressive Disorder | Medical Necessity |
90837 | Major Depressive Disorder | Medical Necessity |
906 *Rev Code | PTSD | Medical Necessity |
97151 | Autistic Disorder | Medical Necessity |
96132 | Neurological Development | Medical Necessity |
97152 | Autistic Disorder | Medical Necessity |
97155 | Autistic Disorder | Medical Necessity |
97156 | Autistic Disorder | Medical Necessity |
H0010 | Alcohol Dependence | Medical Necessity |
97153 | Autistic Disorder | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J0185 | Malignant Neoplasm, Breast | Medical Necessity |
J7318 | Bilateral Primary Osteoarthritis of Knee | Medical Necessity |
J3032 | Chronic Migraine w/o Aura | Medical Necessity |
J0586 | Other Dystonia | Medical Necessity |
J0585 | Chronic Migraine w/o Aura | Medical Necessity |
J7325 | Unilateral Primary Osteoarthritis Right Knee | Medical Necessity |
J7325 | Bilateral Primary Osteoarthritis of Knee | Medical Necessity |
J7318 | Unilateral Primary Osteoarthritis Left Knee | Medical Necessity |
J9299 | Malignant Melanoma, Trunk | Medical Necessity |
J0588 | Dystonia | Medical Necessity |
MHS Prior Authorization Statistics for 2025
2025 calendar year data per SEA 480* - Healthy Indiana Plan (HIP)
*July 1, 2025 – November 30, 2025
Medical | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 28,024 | Medical Appeal Requests Received | 710 | |
Fully Approved | 20,936 | 75% | Overturned | 341 |
Adverse Determinations | 6,717 | 24% | Upheld | 308 |
Partial Approvals | 90 | 0.3% | Partial Approval | 2 |
Average time between submission and response | 2 days *Includes RFI |
| 18 Days | |
Behavioral | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 4,575 | Behavioral Appeal Requests Received | 169 | |
Fully Approved | 4,033 | 88% | Overturned | 19 |
Adverse Determinations | 94 | 2% | Upheld | 143 |
Partial Approvals | 207 | 4.5% | Partial Approval | 7 |
Average time between submission and response | 2.08 days *Includes RFI |
| 16 Days | |
Pharmacy | Total | Percent |
| Total |
|---|---|---|---|---|
Prior Authorization Requests Received | 25,040 | Pharmacy Appeal Requests Received | 332 | |
Fully Approved | 12,104 | 48.3% | Overturned | 87 |
Adverse Determinations | 12,936 | 51.7% | Upheld | 217 |
Partial Approvals | 0 | 0 | Partial Approval | 0 |
Average time between submission and response | 0.53 Days *Includes RFI |
| 14 Days | |
Top 10 reasons for adverse determinations
Medical | Behavioral | Pharmacy |
|---|---|---|
Medical Necessity | Medical Necessity | Medical Necessity |
|
|
|
|
|
|
|
|
|
|
|
|
Top 10 CPT Codes submitted
Medical | Indication Offered | Reason for denial |
|---|---|---|
97116 | Low Back Pain | Medical Necessity |
93307 | Chest Pain | Medical Necessity |
74176 | Abdominal Pain | Medical Necessity |
72148 | Radiculopathy Lumbar Region | Medical Necessity |
71250 | Solitary Pulmonary Nodule | Medical Necessity |
70551 | Headache, Unspecified | Medical Necessity |
73720 | Pain, Right Knee | Medical Necessity |
72141 | Radiculopathy, Cervical | Medical Necessity |
97533 | Pain Right Shoulder | Medical Necessity |
71271 | Nicotine Dependence | Medical Necessity |
Top 10 CPT Codes submitted
Behavioral | Indication Offered | Reason for denial |
|---|---|---|
H0010 | Alcohol Dependence | Medical Necessity |
H2034 | Alcohol/Drug Abuse Half-Way House | Medical Necessity |
H0015 | Stimulant Dependence | Medical Necessity |
H0035 | Opioid Dependence | Medical Necessity |
90837 | Major Depressive Disorder | Medical Necessity |
96130 | Major Depressive Disorder | Medical Necessity |
906 *Rev Code | Cannabis Dependence | Medical Necessity |
90867 | Major Depressive Disorder | Medical Necessity |
90868 | Major Depressive Disorder | Medical Necessity |
Top 10 CPT of J-Codes submitted
Pharmacy | Indication Offered | Reason for denial |
|---|---|---|
J7323 | Primary Osteoarthritis Right Knee | Medical Necessity |
J7318 | Primary Osteoarthritis Right Knee | Medical Necessity |
J7325 | Primary Osteoarthritis Left Knee | Medical Necessity |
J7318 | Primary Osteoarthritis Left Knee | Medical Necessity |
J0585 | Chronic Migraine w/o Aura | Medical Necessity |
J7325 | Bilateral Primary Osteoarthritis Right Knee | Medical Necessity |
J7323 | Unilateral Primary Osteoarthritis Left Knee | Medical Necessity |
J0585 | Anal Fissure Unspecified | Medical Necessity |
J0585 | Chronic Migraine w/o Aura | Medical Necessity |
J7323 | Bilateral Primary Osteoarthritis of Knee | Medical Necessity |