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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

Psychological Testing Request Forms

Transcranial Magnetic Stimulation (TMS) & Electroconvulsive Therapy (ECT) Forms

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