Indiana Medicaid Prior Authorization Form for Imaging and DME: What Reviewers Expect
- Jamie P
- Sep 15
- 9 min read
Submitting a medical prior authorization (PA) to Indiana Medicaid can feel like threading a needle—especially for imaging and durable medical equipment (DME). Approvals often hinge on three deceptively simple elements: choosing the right channel and form, presenting codes and units correctly, and attaching evidence that maps directly to policy criteria. Do those three things well and you’ll see clean, fast decisions. Miss any one of them and you invite pends, denials, resubmissions, and rescheduling headaches for patients and staff alike.
This deep-dive gives you a practical, field-tested blueprint for Indiana Medicaid imaging and DME authorizations. You’ll see exactly what reviewers look for, what to attach (reports—not just orders), how to document medical necessity in one page, and how to avoid the unit-math mistakes that cause instant pends. You’ll also get realistic timelines, appeal tips, and templates you can drop into your SOP today.
Indiana Medicaid At A Glance: Where Prior Authorization Lives
Indiana Medicaid is delivered through two broad pathways, and your PA process depends on which path your patient is on:
Managed Care (MCE): Most members are enrolled in a Managed Care Entity noted on the member ID card. Each MCE operates its own PA intake (portal and/or form) and may contract specialized vendors for certain services (e.g., imaging management or DME).
Fee-For-Service (FFS): A smaller subset of members are covered under the state’s FFS program and use the Indiana Health Coverage Programs (IHCP) Provider Healthcare Portal or state-listed forms.
Because benefits and workflows vary by plan type, MCE, and service category, always start by confirming member eligibility and plan/MCE before you touch a form. Then confirm whether your request is under the medical benefit (imaging, procedures, DME billed on professional or facility claims) versus the pharmacy benefit (NDC-billed drugs filled at a pharmacy).
Choosing The Correct Channel And Form
Picking the wrong lane is the fastest way to create a loop. Use this quick triage:
Imaging (CT, MRI, MRA, PET, some nuclear studies): Check your member’s plan/MCE portal. Some plans require requests to flow through an imaging-management vendor; others take requests directly in their portal. The FFS path uses the IHCP Provider Healthcare Portal for supported codes; when the portal lacks the category, use the state’s current medical PA form and the submission method listed there.
DME (Standard vs. Custom, Rental vs. Purchase): DME frequently requires prior authorization, especially custom or higher-cost items, power mobility, oxygen equipment, and long-term rentals. Most requests are routed through the member’s MCE portal; FFS submissions use the IHCP portal or state form depending on the code.
Rule of thumb: If a portal supports the service line, use the portal—you’ll get structured fields, fewer missing-data pends, and a confirmation number to track. If the service line isn’t supported in the portal, download the current state or MCE form and submit with clearly labeled attachments through the channel listed on the form.
The Clean Submission Blueprint Reviewers Expect
Whether you’re in an MCE portal or filling out a PDF, reviewers scan for completeness, consistency, and clinical necessity. Build your submission around six essentials:
Member And Coverage Snapshot
Member name, DOB, ID number, and plan/MCE
Referring and rendering provider names, NPIs, TINs, and contact numbers
Place of service (POS) and facility NPI/address (for imaging and some DME fits)
Exact Services: Codes, Units, Dates
CPT/HCPCS codes and units for each requested service
Laterality/modifiers as applicable (RT/LT, 26/TC for imaging components, KX modifiers for select DME when appropriate)
Proposed date(s) of service and episode window
Diagnosis And Severity
ICD-10 codes mapped to the service
A one-paragraph function-forward snapshot: ADL limitations, safety risks, quantified severity scores when relevant
Conservative Treatment And Outcomes
Named interventions with dates and durations (e.g., PT six weeks, NSAIDs eight weeks, orthotics, injections)
Objective outcomes (validated scales, range of motion, usage logs)
Documented contraindications or adverse events to alternatives
Reports, Not Orders
Radiology reports (actual impressions), not scheduling orders
Sleep studies, echo reports, labs tied to safety and appropriateness
DME measurements, home assessments, wheelchair evaluations, and trial documentation (if applicable)
Medical Necessity Rationale And Monitoring
A concise, policy-aligned rationale—no literature dump
Risk plan (e.g., contrast safety, anesthesia, home safety for equipment) and follow-up milestones
Formatting tip: Put these elements into a one-page summary with bold micro-headings (Diagnosis, Conservative Care, Imaging/Labs, Rationale, Risk & Follow-Up). Attach reports separately and label them clearly (e.g., MRI_Lumbar_2025-03-12.pdf). Reviewers read faster when your story is consistent and predictable.
Imaging: What Indiana Medicaid Reviewers Look For
Imaging requests (CT, MRI/MRA, PET, some nuclear studies) are frequent PA candidates. Here’s how to make them easy to approve.
Indication And Yield
Briefly answer: Why this study, right now, for this patient? Anchor to clinical red flags, failure of conservative management, or pre-surgical planning. If lesser imaging was done (X-ray, ultrasound), include the report and date. If imaging is being repeated, explain why (e.g., new neurologic deficit, failed therapy, interval change in symptoms).
Component And Site Details
Professional vs. technical vs. global: If you’re only requesting the professional read (–26) or technical component (–TC), align your code/modifier accordingly.
Contrast: If contrast is planned, note renal function and any contraindications.
Site of care: Many plans prefer freestanding centers when appropriate. If you need outpatient hospital, justify with clinical factors (airway risk, comorbidities, need for specific equipment).
Common Pend Triggers And Fast Fixes
Orders without reports → Upload actual reports with impressions.
Mismatch in dose/contrast between the form and the order → Reconcile and re-submit with a one-line correction note.
No prior imaging context when routing to advanced modalities → Provide earlier results or the clinical reason none were indicated.
DME: What Indiana Medicaid Reviewers Look For
DME decisions hinge on medical necessity, safety, and least costly appropriate alternative. Treat your summary like a case for how the equipment restores or maintains function safely at home.
Standard Versus Custom
Standard equipment (e.g., walkers, basic wheelchairs) still may require PA depending on plan thresholds—document functional need, home layout considerations (stairs, narrow halls), caregiver support, and safety risks without the device.
Custom equipment (e.g., complex rehab power wheelchairs, custom orthotics) demands measurements, trial notes, objective fitting information, and confirmation that simpler devices failed or are inappropriate.
Rental Versus Purchase
Some items begin as rental; others qualify for purchase. State in your summary what you’re requesting (and why) and confirm units/duration match your plan’s policy. If oxygen or other supply equipment is involved, include testing values and usage.
Documentation Essentials
Face-to-face visit notes that clearly document the condition, functional deficits, and why the device is required now
Home safety assessment if relevant (ramp, doorway width, flooring, bathroom setup)
Therapist evaluations (PT/OT seating and mobility evaluations for wheelchairs and custom seating)
Trial documentation (why lower-tier equipment failed or is unsafe)
Caregiver training plan for safe use and maintenance
Common Pend Triggers And Fixes:
Missing therapist eval for complex mobility → Upload PT/OT seating evaluation with measurements and trial notes.
Unclear home environment → Add a one-paragraph home assessment or therapist note.
No failure of simpler devices → Include trial outcomes or contraindications for off-the-shelf alternatives.
Getting Codes, Units, And Modifiers Right
Imaging Codes And Modifiers
Map CPT to the exact service requested (e.g., MRI with or without contrast).
Use –26 (professional) or –TC (technical) when you’re not requesting the global service.
Add laterality when required (RT/LT) or bilateral indicators (50) per code descriptor.
DME HCPCS And Unit Math
Many HCPCS supply/drug codes bill per unit increment (e.g., “per 10 mg,” “per 100 units,” “per pair”). Show your calculation in a single line to avoid pends.
For rentals, confirm the unit is per month and match the requested duration to policy.
For custom components, list each relevant HCPCS with units and a brief descriptor tying it to the evaluation (e.g., positioning needs, pressure relief).
One-Line Unit Example (DME): “Requesting E1390 oxygen concentrator, rental for 3 months; qualifying test SpO₂ ≤88% at rest documented; monthly units per policy.”
Site Of Care: Why It Matters And How To Document It
For imaging and some DME fits, where the service occurs affects cost, safety, and policy. Reviewers look for alignment between clinical needs and place of service (POS):
11 Office / Freestanding Center: Preferred for many routine imaging services; note contrast safety and monitoring capability if applicable.
22 Outpatient Hospital: Justify when comorbidities, anesthesia considerations, or equipment requirements exceed office capability.
Home: For DME, describe caregiver capacity, safety plan, and what happens if conditions change (e.g., oxygen back-up, power outage plan).
A two-sentence justification in your summary prevents avoidable questions.
Timelines, Turnarounds, And Expedited Review
Turnarounds differ by plan type, service line, and completeness of the submission. You can reduce elapsed time by:
Submitting a complete packet on day one (summary + reports + measurements).
Capturing the confirmation number and the posted turnaround window in your tracker.
Scheduling a follow-up two business days before the window closes.
Responding to pend requests the same day with exactly what the reviewer asked for—no extra noise.
Requesting expedited review only when delay risks serious harm or loss of function; state the clinical reason plainly in your cover note.
Handling Pends And Denials Without Losing Weeks
If pending: Read the pending reason word-for-word and upload the specific missing item (MRI report dated X, therapist seating evaluation dated Y, home assessment photo/plan), plus a two-line note listing exactly what you attached and the case number.
If denied:
Decide whether it’s a documentation gap (fix and resubmit) or a policy interpretation (consider peer-to-peer if offered, or file an internal appeal).
Keep the appeal cover letter succinct: quote the policy criterion and answer it point-by-point, attaching only the evidence that resolves the criterion.
If the member is in an MCE, check that you’re using the MCE’s appeal channel and not the FFS route.
Templates You Can Use Today
One-Page Imaging Medical Necessity Summary
Patient / Plan: [Name, DOB, Member ID, Plan/MCE]Service: [CPT + modifiers; POS/facility NPI; planned DOS]
Diagnosis & Severity: [ICD-10] + brief function-forward snapshot
Prior Studies & Conservative Care: [XR/US report dates + impressions; PT dates/outcomes; meds tried/failed]
Rationale: [Why this modality now; expected impact on management]
Risk & Monitoring: [Contrast safety; anesthesia; discharge plan]
Attachments: [Report files listed with dates]
DME Letter Of Medical Necessity
Patient / Plan: [Name, DOB, Member ID, Plan/MCE]
Request: [HCPCS codes + units; rental vs. purchase; duration]
Functional Need: [ADL limits, safety risks, mobility/positioning needs]Trials/Alternatives: [Devices tried; results; contraindications]
Home Setup & Training: [Entry/door widths, bathroom, caregiver capacity; training plan]
Objective Outcomes: [Therapist measures, pressure mapping, gait metrics]
Attachments: [PT/OT eval; measurements; home assessment; photos if allowed]
Clinic Operations: Build A Small “PA Pod” For Reliability
Great outcomes don’t require a huge team—just clear ownership and checklists:
Intake & Routing Lead: Confirms eligibility, plan/MCE, portal vs. form, and correct place of service; launches the request.
Clinical Packager: Drafts the one-page summary, compiles reports/measurements, ensures codes/units/POS align across documents.
Tracker & Escalations: Logs confirmation IDs, watches deadlines, responds to pends day-of, and schedules peer-to-peers/appeals when necessary.
Run a 15-minute weekly huddle to review “Pending > 3 Business Days” cases and fix the top three causes of delay together.
Explore: Finding and Retaining Top Talent
Real-World Examples You Can Mirror
CT Abdomen/Pelvis With Contrast
Codes: CPT for CT A/P with contrast; 1 unit, global or split with –26/–TC
Why: Persistent RLQ pain with red-flag features after negative ultrasound; concern for abscess/complications
Evidence: US report date with findings, labs (WBC, CRP), exam notes
Risk Plan: Contrast nephropathy screen (recent creatinine/eGFR), hydration instructions
Site: Freestanding center unless comorbidities justify outpatient hospital
Power Wheelchair With Custom Seating
Codes: Power base HCPCS + seating/back/positioning components + accessories (each with units)
Why: Severe mobility impairment; unsafe with manual chair due to endurance and upper-extremity limitations
Evidence: PT/OT seating evaluation, measurements, trial notes, home layout; caregiver training plan
Least-Cost Fit: Lower-tier equipment failed or contraindicated; detail dates and outcomes
Rental/Purchase: Requested purchase with maintenance plan; justify per policy
Frequently Asked Questions
Do all Indiana Medicaid plans use the same PA rules?
No. Requirements vary by MCE and by FFS, as well as by service category. Always check the member’s plan/MCE and confirm whether the service requires PA for that plan.
Do approvals expire?
Yes. Most approvals are time-bound or unit-bound. If you reschedule outside the window or need more units, request an update/extension per the plan’s process.
Can I change facilities after approval?
Usually you must update the authorization with the new facility’s NPI and address; don’t assume automatic transfer.
When should I request expedited review?
When a delay risks serious harm or loss of function. State the concrete clinical reason and reference the supporting notes or reports.
What if the request is denied?
Decide quickly between a peer-to-peer (when available) and an internal appeal. Keep the appeal letter short, quote the cited criteria, and attach exactly the evidence that resolves it.
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