MedicaidPrior AuthMedium impact
[Indiana] Utilization Management Hierarchy
CareSource·IN·Prior Authorization
Effective date
Aug 1, 2025
We identified it
May 9, 2026
Summary
CareSource updated the utilization management (UM) and prior authorization (PA) hierarchy for Indiana Hoosier Healthwise and Healthy Indiana Plan members effective August 1, 2025. The new hierarchy establishes the order of clinical guidelines and criteria used for PA decisions: Federal Law → Indiana Code → State Plan → Indiana Administrative Code → MCG National Clinical Guidelines, CareSource PA-UM Policy, and IHCP Policy. This clarifies which standards take precedence when determining medical necessity and PA requirements.
Action Required
Before August 1, 2025: Billing and prior authorization staff must review IHCP Bulletin BT2025102 to understand the updated UM hierarchy. When submitting prior authorization requests for CareSource Indiana Hoosier Healthwise and Healthy Indiana Plan members, apply clinical review criteria in the following order of precedence: Federal Law first, then Indiana Code (IC), State Plan documents, Indiana Administrative Code (IAC), and finally MCG guidelines with CareSource PA-UM policies and IHCP criteria. Update internal PA submission processes and staff training to reflect this hierarchy. Contact your CareSource Health Partner Engagement Specialist with questions about specific PA criteria. Failure to apply the correct hierarchy may result in claim denials or PA request rejections.