Indiana · Prior authorization
Indiana’s 2025 prior-authorization law: what it means for chiropractic
Indiana’s SEA 480 (Public Law 144-2025) took effect July 1, 2025. On fully-insured Indiana plans it bans prior authorization for the first 12 chiropractic visits of each episode of care, puts hard clocks on every decision, and deems a service approved when an insurer misses them. Here is exactly when a payer like Anthem can (and can’t) require prior authorization for chiropractic, and what to do when they get it wrong.
Plan types
Before anything else: which kind of plan is it?
Indiana’s prior-authorization law is state insurance law, so it only binds the plans Indiana is allowed to regulate. This one distinction decides whether the protections below apply at all, and it’s the mistake we see practices make most often, because the patient’s Anthem card can look identical across every category. Verify the plan’s funding type at eligibility, before you rely on any of these rights.
A large share of “Anthem” employer coverage is actually self-funded: the employer pays the claims and Anthem only administers them. Those plans are governed by federal ERISA law, not Indiana’s statute, so the 12-visit rule and the deadlines below simply don’t apply. The card often says something like “administered by” Anthem; a 30-second eligibility and benefits check tells you the funding type for certain. This is the same front-end verification that prevents most eligibility denials. See our insurance-verification guide.
The 12-visit rule
No prior authorization for the first 12 chiropractic visits of each new episode of care.
This is the provision that matters most for chiropractic. Under Indiana Code § 27-1-37.5-13.7, a utilization review entity may not require prior authorization for the first twelve (12) physical therapy or chiropractic visits of each new episode of care. It applies to plans subject to the chapter (i.e., fully-insured Indiana commercial plans) as they are issued or renewed on or after July 1, 2025.
Two carve-outs written into the statute itself: § 27-1-37.5-13.7(a) says the 12-visit rule does not apply to state employee health plans or to the Medicaid program. So Anthem’s Indiana Medicaid / HIP line and the state employee plan still follow their own prior-authorization and visit rules for chiropractic. The free-12-visits win is a fully-insured commercial benefit.
One nuance worth understanding: the ban is on requiring prior authorization specifically. Some payers manage chiropractic partly through retrospective medical-necessity review on the claim rather than a prospective authorization, a different mechanism the 12-visit rule doesn’t directly touch. The practical win is largest wherever the payer was demanding an up-front authorization before you could treat.
Decision deadlines
When Anthem can require prior authorization, it’s now on a deadline, and misses count against it.
For services that still require authorization on a covered plan, the law sets firm response windows and, crucially, a self-executing penalty when they’re blown.
24 hours urgent, 48 hours everything else.
The utilization review entity must respond with an authorization or an adverse determination within 24 hours for an urgent service, and within 48 hours for any non-urgent service or prescription (excluding weekends and legal holidays).
Miss the deadline, and the service is authorized.
If the entity fails to meet the deadlines or the chapter’s other requirements, the service subject to prior authorization is automatically deemed authorized. This is the most useful tool on the page: a documented, time-stamped submission turns a late payer response into an approval.
Approval validity
It has to stick, and travel with the patient.
SEA 480 also stops the two games that used to erase an approval you already had.
On an adverse determination, the entity must offer a peer-to-peer review with a clinical peer, and the appeal of a non-certification must be decided by a provider in the same discipline (Indiana Code § 27-8-17-12), meaning a chiropractic denial gets reviewed by a chiropractor, not a generalist medical director.
Gold-card program
Indiana has a prior-auth-reduction program, but it is not the approval-rate “gold card” you may have heard about.
A separate 2023 law (Indiana Code Chapter 27-1-37.6, added by HB 1004) lets a provider qualify for reduced or eliminated prior authorization, but not by maintaining a high past approval rate the way Texas-style gold-carding works. To qualify, a provider must enter both a value-based reimbursement agreement and an electronic-medical-records access agreement with the health plan, and the program is one the plan establishes (“may qualify” is permissive, not automatic). It also excludes Medicaid managed-care organizations.
Bottom line: don’t count on “our approval rate is high, so Anthem has to stop requiring PA.” Indiana didn’t adopt that. The real, automatic protections are the ones above: the 12-visit ban, the deadlines, and deemed approval.
ASH & Carelon
Your Anthem claim splits across two reviewers, by code, not by your license.
Here’s the part that trips up chiropractic billing in Indiana: on an Anthem plan a single one of your claims can go to two different reviewers, split by CPT code. The spinal manipulation (CMT 98940 to 98943) is reviewed by American Specialty Health (ASH) through ASHLink, the specialty-network vendor Anthem uses for chiropractic. But the therapy and physical-medicine codes you also bill (therapeutic exercise (97110), neuromuscular re-education (97112), manual therapy (97140), therapeutic activities (97530) and the modalities) sit on Carelon Medical Benefits Management’s rehabilitation list, because that program is scoped by CPT code, not by your license: its own guideline applies to a physical therapist “or other provider type… duly licensed… to deliver physical therapy,” which is exactly how a chiropractor’s therapy codes land in Carelon’s lane. So one Indiana visit can touch two vendors with two rule sets.
Which codes actually need authorization is set by the member’s product (Indiana runs its own Carelon rehab list, separate from other states and from its Medicaid and Medicare Advantage lists), so verify by CPT and by member plan at eligibility rather than assuming. And SEA 480’s 12-visit ban sits on top of both vendors: because the statute ties the protection to the type of care, not the biller’s license (“the first twelve physical therapy or chiropractic visits”), neither ASH nor Carelon can require prior authorization for the first 12 visits of an episode (including the therapy codes a chiropractor bills), and Carelon’s rehabilitation review can only begin from visit 13. On Medicare Advantage, Anthem follows CMS’s federal rules instead (the 2024 CMS Medicare Advantage rule requires an approval to stay valid for the full course of treatment and adds its own 90-day continuity protection). On HIP / Medicaid, chiropractic follows Indiana Health Coverage Programs (IHCP) rules, which run on their own separate Carelon list. The 12-visit ban does not apply.
Provider remedies
What you can actually do about an improper PA demand or denial.
Indiana’s law is only useful if someone works it. On a covered (fully-insured Indiana) plan, here is the escalation path, and the leverage at each step.
The enforcement hook matters: under § 27-1-37.5-15, a violation of the prior-authorization chapter is an unfair or deceptive act or practice in the business of insurance (IC 27-4-1-4), which the Indiana Department of Insurance can act on. For self-funded / ERISA patients the state route doesn’t apply; you use the plan’s federal ERISA appeal and external-review process; for Medicare Advantage, the CMS appeals process.
For your billing
What this changes for your front desk and your billing.
Know what you’re dealing with
Every patient: is it fully-insured Indiana commercial, self-funded/ERISA, MA, or HIP? It decides which rights exist. Capture it at eligibility, before the first visit.
The clock is your friend
Log the exact submission date and time of every authorization request. A documented 24h/48h miss is a deemed approval, but only if you can prove when you sent it.
Don’t write it off
Peer-to-peer, same-discipline appeal, then IDOI external review. The rights are only worth something if someone files, which is exactly what a dedicated coordinator does.
This is the day-to-day work ACB does for Indiana practices: verifying funding type up front, tracking the authorization clocks, invoking deemed approval on late responses, and running peer-to-peer and same-discipline appeals to the finish, inside the EHR you already use, for one flat fee. It pairs directly with our denials playbook and the CMT coding rules that keep the claim clean in the first place.
FAQ
Indiana chiropractic prior authorization, answered.
It depends on the plan. On a fully-insured Indiana commercial plan issued or renewed on or after July 1, 2025, Indiana’s SEA 480 bars prior authorization for the first 12 chiropractic visits of each episode of care. Beyond that, or on other services, Anthem’s delegate American Specialty Health (ASH) may still review medical necessity. On self-funded/ERISA, Medicare Advantage, and Medicaid/HIP plans, the Indiana 12-visit rule does not apply; those follow federal or Medicaid rules.
On a covered fully-insured Indiana plan, the first 12 visits of each new episode of care cannot require prior authorization (Indiana Code § 27-1-37.5-13.7), and because the statute covers “physical therapy or chiropractic,” that protects both your adjustments and the therapy codes you bill. Past 12 visits, review can resume: the manipulation (CMT 98940 to 98943) through Anthem’s chiropractic delegate ASH, and the therapy / physical-medicine codes (97110, 97140 and the modalities) through Carelon’s rehabilitation program. Total coverage is still capped by the member’s plan rider, so verify the visit benefit by code and plan.
Often, and from a different reviewer than your adjustments. Anthem carves chiropractic manipulation (CMT 98940 to 98943) to American Specialty Health (ASH), but the physical-medicine and therapy codes you bill (97110, 97112, 97140, 97530 and the modalities) sit on Carelon Medical Benefits Management’s rehabilitation list, which is scoped by CPT code regardless of your license. On an Indiana commercial plan the exact codes that require authorization come from Anthem’s Indiana-specific Carelon list (Medicaid and Medicare Advantage use different lists), so verify by CPT and by member plan. SEA 480’s first-12-visit protection still applies to those therapy visits, so Carelon review can only begin from visit 13.
The service is automatically deemed authorized (Indiana Code § 27-1-37.5-28). The decision windows are 24 hours for urgent and 48 hours for non-urgent requests. This only helps if you can prove your submission time, so time-stamp every request.
No. SEA 480 is state insurance law, so it reaches fully-insured Indiana plans only. Self-funded/ASO employer plans are governed by federal ERISA law and are not bound by it, and Medicare Advantage follows federal CMS rules (which have their own, similar prior-authorization protections). The statute’s 12-visit rule also expressly excludes Medicaid and the state employee health plan.
Not the approval-rate kind. Indiana Code Chapter 27-1-37.6 (2023) lets a provider qualify for reduced prior authorization only by entering both a value-based reimbursement agreement and an electronic-medical-records access agreement with the plan, in a program the plan establishes. It is not an automatic exemption based on your past approval rate.
Official sources
Where these rules come from
Every figure on this page is drawn from the primary Indiana statute and Anthem’s own materials. Prior-authorization rules and plan riders change, so confirm the current requirement for a specific member and plan.
- Indiana General Assembly: Senate Bill 480 (2025), Public Law 144-2025
- Indiana Code § 27-1-37.5: Health Care Service Prior Authorization
- Indiana Code § 27-1-37.6: Program to Reduce or Eliminate Prior Authorization
- Indiana Department of Insurance: Internal & external grievance/appeal procedures
- Anthem Indiana: Prior authorization requirements & lookup
- Anthem Indiana Provider News: Carelon rehabilitation solution update (PT/OT/ST), eff. Oct 1, 2025
- Carelon Medical Benefits Management: Rehabilitation (PT/OT/ST) clinical guidelines (“qualified provider” scope)
- Carelon: Anthem BCBS Indiana Commercial rehabilitation CPT code list (97110/97112/97140/97530 + modalities)
- Anthem Indiana Provider News: Carelon musculoskeletal & surgical programs, effective Mar 1, 2025
- CMS: 2024 Medicare Advantage final rule (prior authorization)
This page is part of our Indiana chiropractic billing hub. For the coding rules that keep these claims clean, see the CMT / CPT code guide and the claim-denials playbook.
This page is general information for chiropractic practices and billers. It is not legal advice, and prior-authorization rights turn on plan-specific facts (funding type, effective date, the member’s benefit). Verify the current requirement for each member and plan, and consult counsel for a specific dispute. American Chiropractic Billing summarizes these rules to help clients bill correctly; we are a billing service, not a law firm.
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Indiana chiropractic billing · Prior-auth tracking · Denials & appeals worked · Any-EHR · Month-to-month