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 (commercial ABA providers only)
ABA Treatment Plan - electronic submissions

Psychological Testing Request Forms

Optum Psych Testing Request Form - electronic submission

Transcranial Magnetic Stimulation (TMS) Forms

TMS Authorization Request Form (NEW) - electronic submission

Uniform Treatment Plans (UTP) Fax completed UTP forms to 1-877-235-9905

Indiana UTP

All other Non-Routine Services - Indiana Electronic Submission Form - commercial providers only

Indiana Prior Authorization Electronic Submissions (1/2020)