Insights

IN State Updates - 2015 Jan 10 No.01


On Feb. 25, 2015, Insurance Commissioner Robertson issued Bulletin 214 encouraging all entities to use a common form, included in the bulletin, for prior authorizations, thereby reducing cost to insurers and providers and reducing delays for patients. This bulletin is directed to all insurers, HMOs, TPAs and other persons involved in reviewing claims and providing prior authorization procedures. Prior authorization includes any preapproval, preauthorization, prior approval, prior notification or similar requirement in a policy or contract, but does not include pre-treatment payment estimates.

Prior authorization requests and approvals should be made in writing to avoid disputes over oral agreements. It is up to the insurer whether prior authorization requests are permitted over the phone or orally when a written request is not possible. The Indiana Insurance Department has worked with many industry representatives and has determined that the recommended form, substantially similar to the common form already in use in Texas, requests the necessary information to determine whether prior approval is appropriate.

The Department is aware that no prior authorization is necessary when a condition is life-threatening. Therefore, this form would not be applicable in those situations. Further, the Department encourages insurers, HMOs, and TPAs not to deny coverage solely for a lack of prior approval when an unforeseen additional related procedure is medically necessary during an authorized procedure. Denials should be explained to the requesting provider.

The Department is considering an administrative rule that would require use of a standard prior authorization form. Voluntary use of this form will provide practical experience and yield valuable feedback during any rulemaking.

Coverage for those who qualify began Feb. 1, 2015.

Bulletin 214  »