UM guidelines for timely service preapproval and reimbursement

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as members’ coverage according to their health plan. It is important to know that we do not reward providers or other individuals for issuing denials of coverage, service, or care, we do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits, and we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization.

Precertification rules can be found using our Precertification lookup tool. Our state‑approved medical policies and UM criteria are available online via our provider website.

Staying informed about the UM process is crucial for optimizing patient care and streamlining administrative functions and claims submissions. This guide details submission methods, necessary documentation, and contact information, ensuring you have the resources to facilitate approvals efficiently.

Precertification requests

• Precertification requests may be submitted for review and approval as outlined below:
• Digital submission (preferred method): https://Availity.com
• Phone: 866‑408‑6132 (Hoosier Healthwise), 844‑533‑1995 (Healthy Indiana Plan), 844‑284‑1798 (Hoosier Care Connect), or 833‑569‑4739 (Indiana PathWays for Aging)
• Fax:
• Inpatient/outpatient medical: 866‑406‑2803
• Pharmacy (retail): 844‑864‑7860
• Medical injectable: 888‑209‑7838
• Behavioral health inpatient: 844‑452‑8074
• Behavioral health outpatient: 844‑456‑2698
• Behavioral health Indiana PathWays for Aging: 877-410-0623

Our state-approved medical policies and UM criteria are available here, or you can request a free copy by calling 866-902-4628, option 1.

Peer‑to‑peer review process

For peer‑to‑peer discussions regarding a request being reviewed by a medical director, please call the peer‑to‑peer direct number: 866-902-4628, option 1.

Please note: Peer‑to‑peer requests must be submitted within seven business days for Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect, and 15 business days following your initial request decision for Indiana PathWays for Aging.

Be prepared to provide the following information:

• Name of person/physician our medical director needs to call
• Contact number
• Convenient time for a return call
• Authorization/reference number for the case
• Member’s name, date of birth, and health plan ID number

What if I need assistance?

We have staff available to help with UM issues Monday through Friday, during regular business hours for inbound collect or toll‑free calls. We can also receive fax communications after regular business hours. Messages will be returned within one business day. When initiating or returning calls, our staff will identify themselves by name, title, and organization name. TDD/TTY and language assistance services are available for members as needed at no cost.

If you have questions about UM decisions or the UM process, call Provider Services at 866‑408‑6132 (Hoosier Healthwise), 844-533-1995 (Healthy Indiana Plan), 844-284-1798 (Hoosier Care Connect), or 833-569-4739 (Indiana PathWays for Aging).