BCBS of Indiana Prior Authorization: Carelon, Reforms, and Appeals

Anthem Blue Cross and Blue Shield of Indiana requires prior authorization — advance approval from the plan — before providers deliver certain services, procedures, and medications to members enrolled in its commercial, Medicaid (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect), Indiana PathWays for Aging, and Medicare Advantage plans. The BCBS Indiana prior authorization process runs primarily through the Availity Essentials portal, decisions are bound by Indiana’s statutory timelines of 48 hours for urgent requests and five business days for standard requests, and denials can be challenged through reconsideration, peer-to-peer review, or a formal appeal filed within 60 days.¹

What Needs Prior Authorization

On Anthem’s Indiana Medicaid plans, the member’s primary medical provider is responsible for initiating any prior authorization request. The service categories that generally require it include inpatient hospital admissions, air ambulance transport, certain behavioral health services, home health and hospice care, infusion therapy and chemotherapy, genetic testing, transplant services, select outpatient surgeries, some laboratory and radiology services, drug injections, biofeedback, hyperbaric oxygen therapy, sensory integration therapy, and certain durable medical equipment.²

Any service delivered by or arranged at an out-of-network facility requires precertification, regardless of the service type. Behavioral health services billed under specific revenue codes are also always subject to precertification, including all-inclusive ancillary psychiatric services (0240–0249), behavioral health treatment services (0901, 0905–0907, 0913, 0917), other therapeutic services (0944–0945), and psychiatric professional fees (0961).³

To check a specific outpatient CPT or HCPCS code, providers can use Anthem’s Precertification Lookup Tool on the provider website or within Availity Essentials, filtering by line of business. The tool covers outpatient services only, and it does not confirm whether a service is actually covered under a member’s benefits, so eligibility has to be verified separately.⁴

How to Submit a Request

The primary electronic route is the Interactive Care Reviewer (ICR), a utilization management application inside the Availity portal. Providers log into Availity Essentials, open the Patient Registration tab, and choose Authorizations to create a case, attach clinical documentation, check status, and receive the decision without phoning or faxing. Anthem states the system can auto-authorize more than 40 common procedures.⁵

Phone lines run Monday through Friday, 8 a.m. to 8 p.m. ET:

Hoosier Healthwise: 866-408-6132
Healthy Indiana Plan: 844-533-1995
Hoosier Care Connect: 844-284-1798
Indiana PathWays for Aging: 833-569-4739

Fax numbers are divided by service type. Physical health requests (inpatient and outpatient) go to 866-406-2803, and concurrent inpatient reviews to 844-765-5156. Carelon-managed services such as durable medical equipment, home health, wound care, and orthotics use 844-765-5157. Retail pharmacy requests go to 844-864-7860, and medical injectable pharmacy requests to 888-209-7838.³ Effective January 1, 2026, the Indiana PathWays for Aging Dual Care (FIDE D-SNP) plan uses a separate fax number, 866-959-1537.⁶

How Long Anthem Has to Decide

Indiana state law sets stricter baseline deadlines than federal CMS rules. Insurers must complete decisions within 48 hours for urgent care requests and within five business days for all other requests. Federal CMS rules that took effect in January 2024 allow 72 hours for expedited and seven calendar days for standard requests, but those apply only when state law is not shorter, and Indiana’s is.¹

Anthem’s own published physical health turnarounds are seven calendar days for standard non-urgent pre-service requests, three calendar days for urgent pre-service, and one business day (up to three calendar days) for emergent inpatient admissions and concurrent reviews after the necessary clinical information is received.⁷ A more recent Anthem presentation references tighter turnaround times under Senate Enrolled Act 480: 48 hours for standard non-urgent pre-service, 24 hours for urgent or expedited pre-service, and 48 hours for concurrent reviews, excluding weekends and holidays.⁸

Behavioral health decisions vary by level of care. Acute inpatient, residential substance use disorder, and transcranial magnetic stimulation requests are decided within one business day (up to three calendar days). Outpatient therapy, applied behavior analysis, psychological testing, and similar services carry a seven-calendar-day turnaround.⁷ Medical necessity for behavioral health is evaluated using non-customized Milliman Care Guideline criteria for psychiatric requests, and a combination of Milliman and American Society of Addiction Medicine criteria for substance use disorder requests, alongside state-approved Anthem clinical guidelines.⁸

Pharmacy prior authorization on Medicaid plans is reviewed and decided within 24 hours. When a medication is needed immediately, a member may be able to obtain a 72-hour emergency supply while the request is pending.⁹

Common reasons a drug needs prior authorization include the availability of a generic or preferred alternative, nonpreferred status on the Preferred Drug List, potential for misuse, a step-therapy requirement to try other medications first, dosages above recommended levels, or quantities beyond normal expectations.⁹ As of February 2026, Anthem added prior authorization for 38 specialty pharmacy medications billed under the medical benefit, covering immunoglobulins, oncology agents, and VEGF/ophthalmology drugs, and designated ten drugs as nonpreferred subject to step therapy.¹⁰

Services Reviewed by Carelon

Anthem delegates prior authorization review for several service categories to Carelon Medical Benefits Management, Inc. (formerly AIM Specialty Health, rebranded in March 2023).¹¹ Carelon handles utilization review for advanced imaging (abdomen, pelvis, chest, head and neck, and oncologic imaging), outpatient rehabilitative and habilitative therapies (physical, occupational, and speech therapy), radiation oncology, genetic testing including hereditary cancer testing, and certain surgical procedures such as upper gastrointestinal endoscopy.¹² Requests for those services go through the Carelon ProviderPortal or Availity Essentials, and Carelon applies its own Clinical Appropriateness Guidelines, which are reviewed and updated annually.

How to Appeal a Denial

When a request is denied, Anthem sends a notice explaining the reason and outlining the options. Providers and members have several paths, each with its own deadline.

A provider can request reconsideration within seven business days of the denial by submitting additional clinical information marked “Reconsideration” on the fax coversheet. Anthem must issue a decision within seven business days. In lieu of, or in addition to, reconsideration, a provider can request a peer-to-peer review — a direct discussion with a physician reviewer — within seven business days of the initial or reconsideration denial by calling 866-902-4628.¹³

A formal appeal must be filed within 60 calendar days of the denial date. Providers can fax clinical documentation to 855-535-7445 for provider appeals or 855-516-1083 for behavioral health appeals. Standard appeals are decided within 30 days; expedited appeals within 48 hours.¹³

Medicaid members (or their designated representatives) can file appeals by phone through Member Services or in writing to Anthem’s Appeals Department at P.O. Box 62429, Virginia Beach, VA 23466, or by fax to 855-516-1083.¹⁴

What Changed Under Indiana’s Reform Laws

Indiana has passed two laws that reshape prior authorization, and both are worth knowing before you contest a denial or plan a course of treatment.

SEA 400 (2023)

Senate Enrolled Act 400, signed by Governor Eric Holcomb on May 4, 2023, and effective July 1, 2023, prohibits the Indiana state employee health plan from requiring prior authorization for 49 commonly requested and routinely approved CPT codes, and bars retroactive denial of those services. The 49 codes were identified through a coalition of the Indiana State Medical Association, the Indiana Hospital Association, the American Physical Therapy Association – Indiana Chapter, and the Indiana Dental Association. The legislature was required to convene a study committee by November 1, 2025, and the pilot program is set to expire on June 30, 2026, unless extended.¹⁵

The same law added a transparency requirement: health plans must post on their websites the 30 most frequently submitted CPT codes for prior authorization along with the approval percentage for each, organized by year on a single accessible page.¹⁶

SB 480 (2025)

Senate Bill 480, authored by State Senator Tyler Johnson (R-Leo), passed the Senate on February 20, 2025, by a vote of 47–2, cleared the full legislature in April 2025, and was signed into law.¹⁷¹⁸ Its key provisions:

Private insurers cannot require prior authorization for the first 12 physical therapy or chiropractic visits for a new injury or episode of care; Medicaid is excluded.¹⁷
Denials and approvals must be handled by a clinical peer with similar training — a physician certified in the same specialty or subspecialty by the American Board of Medical Specialties or the American Osteopathic Association. The law prohibits use of algorithms, artificial intelligence, or non-specialty staff for these decisions.¹⁹
Peer-to-peer reviews and responses following adverse determinations and appeals must be turned around within 24 to 48 hours.¹⁸
Approved authorizations are protected from revocation, and authorizations are portable across insurance plans.¹⁸
The definition of “medically necessary” is tightened to reduce disputes between insurers and providers.¹⁹

Commercial and Medicare Advantage Boundaries

Commercial requirements sit on separate lists from Medicaid and Medicare. Anthem publishes a Blues and CDHP Prior Authorization List for Indiana commercial and consumer-driven plans, and a separate Anthem National Accounts Standard Precertification List for national account employer plans. Both route through Availity Essentials, and coverage decisions follow Anthem’s published medical policies and clinical utilization management guidelines.²⁰ Pharmacy requirements on commercial plans depend on the specific formulary assigned to the member’s plan (Essential, National, and related variants), and members can identify what applies by logging into their Anthem account or contacting Pharmacy Member Services.²¹

Anthem’s Medicare Advantage plans follow federal rules that require Traditional Medicare coverage criteria as the baseline for medical necessity. Internal coverage criteria may be used only when Traditional Medicare criteria are not fully established, and those internal criteria must be publicly posted.²² The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), released in January 2024, applies to Medicare Advantage as well, with general provisions effective January 1, 2026, and API-based electronic prior authorization requirements following on January 1, 2027.²³

1
Indiana State Medical Association. POPA FAQ
2
Anthem. Referrals, Preapprovals, and Prior Authorizations
3
Anthem. Prior Authorization Requirements
4
Anthem. Precertification Lookup Tool
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Anthem. Learn About Availity
6
Anthem Provider News. New Fax Number for Indiana PathWays for Aging Dual Care Prior Authorization
7
Indiana Medicaid. Anthem PA 101
8
Indiana Medicaid. Anthem Physical and Behavioral Health PA
9
Anthem. Pharmacy
10
Anthem Provider News. Prior Authorization and Step Therapy Updates for Medications
11
Anthem Provider News. Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines
12
Anthem Provider News. Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
13
Indiana Medicaid. Anthem Prior Authorization 101
14
Anthem. Complaints and Grievances
15
Indiana State Medical Association. 49 CPT Codes No Longer Need Prior Authorization Starting July 1
16
Employers Forum of Indiana. Indiana Legislative Health Summary
17
WFYI. Prior Authorization Reform Heads to Governor’s Desk After Final Senate Approval
18
Indiana APTA. Huge Legislative Win for Indiana PT
19
Indiana Capital Chronicle. Senators Move Prior Authorization, PBM Regulations
20
Anthem. Prior Authorization – Individual and Commercial
21
Anthem. Drug List and Formulary
22
CMS. Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program
23
CMS. CMS Interoperability and Prior Authorization Final Rule