Streamline Operations and Ensure Compliance with Banjo Health
Indiana is actively reforming its prior authorization (PA) landscape. Recent legislative efforts, including Senate Bill480, reflect the state's commitment to enhancing transparency, reducing administrative burdens, and ensuring timely access to care. For payers and PBMs, adapting to these evolving requirements is crucial. Banjo Health offers an intelligent automation platform designed to align with Indiana's PA regulations, ensuring compliance and operational efficiency.
Key Provisions of Indiana’s Prior Authorization Reforms
Senate Bill 480, passed in early 2025, introduces significant changes:
● Specialty-Matched Clinical Review: Denials must be reviewed by a physician licensed in Indiana and in the same or a similar specialty as the requesting provider. This move ensures that decisions are clinically sound and contextually appropriate.
● Definition of Medical Necessity: The bill tightens the definition of "medically necessary" to prevent disputes between insurers and providers, promoting clarity and consistency in coverage decisions.
While initial proposals included caps on prior authorization denials and exemptions for low-cost medications, these provisions were removed due to fiscal concerns.
Indiana Medicaid and Managed Care Requirements
The Indiana Health Coverage Programs (IHCP) mandates prior authorization for specific services to document medical necessity:
● Fee-for-Service (FFS): Non-pharmacy PA requests are reviewed by Acentra Health, while pharmacy-related requests are handled by Optum Rx
● Managed Care Entities (MCEs): Programs like Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise have their own PA processes. MCEs must adhere to IHCP policies and cannot implement more restrictive criteria than those established by the state.
Banjo Health integrates seamlessly with both FFS and MCE workflows, ensuring that all PA requests are processed in accordance with state guidelines.
Submission Methods and Timelines
Providers in Indiana can submit PA requests through various channels:
● Electronic Submissions: Preferred method via the Atrezzo Provider Portal or 278 electronic transactions.
● Fax or Mail: Using the appropriate IHCP PA request forms.
● Telephone: For urgent cases, verbal requests are accepted, followed by necessary documentation.
For FFS non-pharmacy services, if a decision isn't made within seven calendar days after receiving all required documentation, the authorization is deemed granted.
Appeals and Administrative Reviews
Providers have the right to request an administrative review of PA denials:
● Timeframe: A written request must be submitted within seven business days of receiving the denial notification.
● Process: The review is conducted by the PA contractor that issued the denial. If the member has changed health plans, providers can appeal to the original contractor or submit a new PA request to the current one.
Banjo Health facilitates this process by maintaining comprehensive records and providing tools for efficient appeal management.
Why Choose Banjo Health for Indiana Prior Authorization Compliance
Banjo Health offers a robust solution tailored to Indiana's PA requirements:
● Automated Workflows: Ensures timely processing of PA requests, reducing administrative burdens.
● Integrated Clinical Criteria: Aligns with IHCP policies and supports specialty-matched reviews.
● Real-Time Tracking: Provides transparency and accountability throughout the PA process.
● Comprehensive Reporting: Facilitates compliance with state reporting requirements and supports continuous improvement.
By leveraging Banjo Health, payers and PBMs can navigate Indiana's PA landscape with confidence and efficiency.
This blog is for informational purposes only and does not constitute legal, regulatory, or professional advice
