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. Funding type and product determine which protections apply, 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 rule removes a prior-authorization requirement for eligible visits; it does not create twelve covered or free visits.
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 plan subject to Chapter 27-1-37.5, the law sets firm response windows and, crucially, a self-executing penalty when they’re blown. These provisions can also apply to Medicaid managed care; the chapter excludes services under the PathWays for Aging and Health and Wellness waivers, local public-employer plans, and federally preempted Medicaid requirements.
24 hours urgent, 48 hours everything else.
The utilization review entity must respond with an authorization or an adverse determination within 24 hours after receiving a request for an urgent service, and within 48 hours after receiving a request for any non-urgent service or prescription (excluding weekends and state and federal 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. For a provider-of-record appeal of a non-certification under Indiana Code § 27-8-17-12, the decision must be made by a provider licensed in the same discipline: a chiropractor’s appeal gets reviewed by a chiropractor. The member’s grievance process is a separate route.
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 can split across two reviewers, by CPT code.
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. Where the member’s plan delegates chiropractic review to American Specialty Health (ASH), the spinal manipulation (CMT 98940 to 98943) goes through ASH. The therapy and physical-medicine codes you also bill (therapeutic exercise (97110), neuromuscular re-education (97112), manual therapy (97140), therapeutic activities (97530) and listed modalities) sit on Carelon’s Indiana commercial rehabilitation list. Check the member’s product, each CPT code and provider eligibility to establish the review route for those services. So one Indiana visit can touch two vendors with two rule sets.
Carelon’s current FAQ describes eligible Anthem BCBS Indiana commercial fully insured PT episodes as exempt for the first 12 treatment visits, with authorization from visit 13 (effective October 1, 2025). It separately describes OT/ST and ASO/self-funded therapy authorization from the first treatment visit after the evaluation. For a chiropractor’s therapy line, verify the member, CPT, provider eligibility and how the service and episode are classified; the FAQ does not establish that every therapy code billed by a DC is an exempt PT visit. Keep this check alongside SEA 480’s chiropractic-visit protection. Medicare Advantage follows federal and plan rules; Medicaid/HIP follows IHCP and the applicable program requirements. Neither uses the state’s 12-visit exemption.
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.
Act quickly after a denial. Under § 27-1-37.5-23(f), notify the review entity of a provider appeal within 48 hours after receiving the adverse determination; it must respond within 48 hours. Weekends and state and federal legal holidays are excluded. Request peer-to-peer review promptly and preserve that appeal deadline. A violation of the chapter is an unfair or deceptive insurance practice under § 15, and IDOI has a provider complaint channel. 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, a timely provider appeal, and the member’s external-review route when available. 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.
For plans subject to Indiana Code § 27-1-37.5-13.7, the first 12 chiropractic visits of each new episode cannot require prior authorization. That exemption does not guarantee coverage or automatically classify every therapy code billed by a DC as exempt PT. Check benefit limits, the CPT code, the member’s product and the applicable episode rules. After the exemption, confirm whether review is required and whether the plan delegates it to ASH, Carelon or another reviewer.
Therapy codes can need a different review route from your adjustments. Carelon’s Indiana commercial list includes 97110, 97112, 97140 and 97530. Its current FAQ distinguishes eligible fully insured PT episodes from OT/ST and ASO/self-funded therapy. Confirm provider eligibility, the service’s classification, the episode count and any applicable exemption for each code and member before treatment. ASH review of CMT, where delegated, is a separate check.
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, excluding weekends and state and federal legal holidays. This only helps if you can prove your submission time, so time-stamp every request.
The 12-visit exemption does not bind ERISA self-funded employer plans, and Medicare Advantage follows federal CMS rules. The exemption also expressly excludes Medicaid and the state employee health plan. The decision clocks and deemed-authorization rule have the separate chapter exclusions described above. The gold-card program excludes Medicaid managed-care organizations. Use the member’s IHCP program and payer guidance to identify the applicable requirements.
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
Use the member’s product, CPT code, provider eligibility and episode classification to confirm the applicable requirements. The linked Carelon documents describe its program; they do not establish every statutory deadline.
- MHS Indiana: SEA 480 implementation, Medicaid decision deadlines
- Carelon: Rehabilitation Program FAQ (updated July 21, 2026), Indiana PT/OT/ST & ASO rules
- 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 Medicaid/HIP: 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)
- Indiana Code § 27-8-17-12: provider-of-record appeals and same-discipline review
- Indiana Department of Insurance: provider complaint form
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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