Indiana Prior Authorization Rules

Overview

Indiana Code Section 27-13-36 sets standards for utilization review and prior authorization practices. Insurers must respond to standard prior authorization requests within 3 business days of receiving complete clinical information and to expedited/urgent requests within 1 business day. Denial notices must include the specific clinical criteria not met and the evidence-based clinical rationale for the denial. Patients have rights to internal appeal (180 days) and external review through the Indiana Department of Insurance.

Key Requirements

1. Standard PA Timeline: Three business days from receipt of complete clinical information to approve, deny, or request additional information.
2. Expedited/Urgent PA Timeline: One business day for expedited requests when a standard timeline would adversely affect patient care.
3. Emergency Exception: Prior authorization is not required for emergency services.
4. Denial Notice Requirements: Denial letters must include the specific clinical criteria relied upon, evidence-based clinical rationale for the denial, and full appeal instructions.
5. Internal Appeal Rights: Patients and providers have 180 days to file internal appeals. Expedited appeals are decided within 1 business day for urgent matters.

Penalties and Enforcement

The Indiana Department of Insurance (IDOI) enforces prior authorization requirements. Violations include missing response deadlines, issuing denials without adequate clinical rationale, and failing to provide complete appeal instructions. Insurers in violation are subject to enforcement action, market conduct examinations, and civil penalties. IDOI may require corrective action plans.

Appeals and Exceptions

All patients and providers have the right to appeal any prior authorization denial. Internal appeals must be submitted within 180 days and are decided within 30 days. Expedited internal appeals are decided within 1 business day for urgent requests. External review through the Indiana Department of Insurance is available if the internal appeal is denied or no response is received within 30 days. Emergency services have no PA requirement.

Interaction with Federal Law

Indiana's PA requirements under IC 27-13-36 operate alongside federal regulations under CMS-0057-F (beginning 2026-2027). These rules do not preempt Indiana state law; whichever provides stronger protection applies. Self-funded ERISA plans follow federal requirements; state-regulated plans must comply with both Indiana law and federal standards.

Common Questions