Prior Authorization

Please note: Starting 04/01/2024, the PA Department will no longer be reviewing Medicaid Authorization requests that are received more than 14 days after admission.  The PA Department will respond to the request with our Retro Authorization Administrative Denial.

 

Prior Authorization Forms

 

Outpatient PA Form   Inpatient PA Form   Subacute PA Form    

To review for medical necessity, please submit the following:

• Prior Authorization Request Form
• Current Clinical Notes
• Supporting Documentation
• Physician/Provider Order 

 

For further guidance, please visit the Authorization Requirements page.

These forms and other documents can be found on Prior Authorization Documents or Provider Documents.

Please reach out to the Prior Authorization Department with questions by calling 1-855-839-1032 or emailing paassistants@icarehealthplan.org.

 

Prior Authorization List (PAL)

Current PAL (pdf)     

The PDF can be searched using the F5 option and the excel version of this document can be filtered by category, code, or description.

To prevent disruption of care, iCare does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to the enrollment. iCare may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment.

 

For dates of service on or after 10/1/2025, iCare will no longer require prior authorization for the following codes for Medicare or Medicaid:

 

DME/Orthotics:

A5500, A5503, A5504, A5506, A5507, A5513, E0185, E0186, E0950, E0974, E0990, E2205,

E2209, E2220, E2323, E2359, E2366, E2367, K0017, K0069, K0072, K0606, L1810, L2755,

L3030, L3150, L3222, L3224, L3225, L3257, L3300, L3320, L3332, L3390, L3808, L4002, L5632,

L5636, L5668, L5684, L5685, L5686, L5688, L5695, L5698, L5850, L5974, L6620, L6660, L6676,

L6682, L8000, L8020, L8030, V2624, V2626

Injections:

J1930, J2323, J2350, J2357

Cardiac Monitoring:

93241, 93242, 93243, 93244, 93246, 93247, 93248, 95700

Enteral Feeding Formula:

B4149, B4155, B4158, B4160, B4161

Urine Drug Screen:

G0480

For Medicaid only – iCare will no longer require prior authorization for the following codes:

 

DME:

K0739

Specialty Drugs:

J0725, J1299, J1300, J1458

 

Services and Procedures Requiring Prior Authorization/Utilization Management Review

Prior authorization is required for:

• Behavioral Health (BH)
  • BH Inpatient Hospitalization
  • Partial Hospitalization Program (PHP)
  • Intensive Outpatient Therapy (IOP)
• Admission to a subacute facility (Skilled Nursing Facility, Long Term Acute Care Hospital, Inpatient Rehabilitation Facility)
• Home health care services
• Personal Care Services
• Hospice
• Select durable medical equipment
• Select procedures
• Outpatient physical, occupational, and speech therapy & cardiac and pulmonary rehabilitation
• Transplants
• Referrals
  • For second (or addition) opinions
  • Referrals to non-participating providers outside of the member’s home state
• For Non-Medicaid certified Providers –All Services other than Emergency Services
• All Category III procedure codes
• Long term care services covered under iCare’s Family Care Partnership Program also require a service authorization request from the Interdisciplinary Team.

Please note that supporting clinical documentation is required for all prior authorization requests in order to determine medical necessity. Incomplete prior authorization requests may delay processing. iCare will not retro authorize services rendered prior to the submission of a prior authorization request.

For information about Pharmacy Part D prior authorizations, coverage determinations or formulary exceptions, visit the Drug Coverage Information for Providers page.

For authorization requirements, visit the Authorization Requirements page. 

 

Should you need to file a formal complaint:    Submit a CMS complaint form online 

 

H2237_IC2203_M 
Last Updated 10/15/25