Indiana Authorization Forms
Plans administered by Optum behavioral do not require prior authorization for routine outpatient services. Optum administers a wide range of benefits.
Click here to confirm member specific eligibility and benefits: this requires log-in (located in upper right corner)
If you do not have an account, you can create one by clicking on First-Time user.
Click here to determine when a prior authorization request is required, as well as any pre-service requirements or required documentation.
Click here to review Clinical Review Criteria used to evaluate prior authorization requests.
Below are the available forms that can be used:
ABA Assessment & Treatment Plan Forms
- ABA Assessment Requests - electronic submission
- ABA Treatment Plan - electronic submissions
Psychological Testing Request Forms
- Optum Psych Testing Request Form - electronic submission
Transcranial Magnetic Stimulation (TMS)
- TMS Prior Authorization Request Process Training
Uniform Treatment Plans (UTP) Fax completed UTP forms to 1-877-235-9905
All other Non-Routine Services - Indiana Electronic Submission Form - commercial providers only