Indiana Health Coverage Programs Prior Authorization Request Form Completed Form Examples and Samples
Explore detailed examples and samples of the Indiana Health Coverage Programs Prior Authorization Request Form. Learn how to accurately fill out IHCP forms with our guided templates and clinical data extraction insights.
Indiana Health Coverage Programs Prior Authorization Request Form Example
How this form was filled:
This example demonstrates how an AI can accurately extract clinical data from an unstructured physician's referral email to populate an Indiana Health Coverage Programs Prior Authorization Request Form. By parsing the physician's narrative, the AI maps complex provider IDs, ICD diagnostic codes, and service descriptions directly into the required state form fields, streamlining the prior authorization process for Medicaid providers.
Source document used: Physician Referral Email
Subject: Prior Authorization Request for Jordan Smith (Member ID: 123456789A) Dear Administrative Team, I am writing to request a prior authorization for my patient, Jordan Smith (DOB: 05/12/1988), who resides at 742 Evergreen Terrace, Springfield, IN 46201. Jordan has been experiencing chronic issues following a recent injury. His contact number for any follow-up is 317-555-0199. We need to begin an intensive course of physical therapy to address his condition. The primary diagnosis is M54.50 (Low back pain), with secondary considerations for M54.2 (Cervicalgia) and R26.89 (Other abnormalities of gait and mobility). Our clinic, Active Recovery Spine Center located at 100 Wellness Way, Indianapolis, IN 46204, will be providing the care. Our NPI is 1234567890 and our Taxpayer Identification Number (TIN) is 99-8765432. The patient's Primary Medical Provider is Dr. Alan Grant (NPI: 9876543210, Phone: 317-555-0000). The rendering therapist will be Sarah Jenkins, PT (NPI: 1122334455), working out of the same clinic address. Please note that the patient is covered under the MHS Hoosier Healthwise plan, so please direct the authorization to them. We are looking to schedule sessions starting 02/01/2026 through 04/01/2026. For the first session on 02/01/2026, we will be using code 97110 with modifier GP, place of service 11, for a total of 1 unit at $150.00. The taxonomy code for our billing is 225100000X. My administrative assistant, Kevin Miller (317-555-9999, Fax: 317-555-8888), has prepared this form. I have signed off on the medical necessity assessment as of today, January 20, 2026. Let me know if you need additional clinical notes.
Information used to fill out the document:
- Patient Details: Jordan Smith, DOB 05/12/1988, ID 123456789A
- Insurance Plan: MHS Hoosier Healthwise
- Clinical Diagnoses: M54.50, M54.2, R26.89
- Provider IDs: Active Recovery Spine Center (NPI: 1234567890)
- Requested Service: Physical Therapy, 97110, 1 unit at $150.00
- Dates of Service: 02/01/2026 to 04/01/2026
What this filled form sample shows:
- Automatic identification of insurance entities from unstructured plan names
- Intelligent parsing of diagnosis codes embedded in prose
- Contextual mapping of provider roles (Rendering vs. Requesting vs. PMP)
- Automated formatting of dates and currency into official form fields
- Extraction of multiple procedure line items from narrative text
Form specifications and details:
| Form Name: | IHCP Prior Authorization Request Form |
| Version: | 9.2, July 2024 |
| State: | Indiana |
| Target Audience: | Fee-for-Service and Managed Care Providers |
| Primary Use Case: | Physical Therapy Authorization Request |
| Created: | July 17, 2026 05:48 AM |