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Prior Authorization

 

Latest Updates Services Requirements PA Documents

 

In an increasingly complex health care environment, iCare is committed to offering solutions that help health care professionals save time and serve their patients. The prior authorization process is in place to assure iCare members receive the appropriate level of care and to mitigate potential fraud, waste, and abuse.

iCare Prior Authorization

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Updates from iCare’s Prior Authorization Department

 

Prior Authorization Form


The PA department has changed the Prior Authorization Request Form for DME, DMS, and Outpatient Procedures to include some critical information that will assist in the proper and accurate entry of an authorization request.

We hope these changes will make the form easier to use and will lead to better completion with less phone calls to determine incorrect or missing information.  Use the form here to submit a prior authorization request. 

Prior Auth Form

 

Prior Authorization Specific Listing


Current Prior Auth Specific Listing/pdf    Current Prior Auth Specific Listing/excel

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

The Prior Authorization Department has added new codes:

*Effective June 1, 2022, the following codes will be added to the list requiring PA:

30468 55880 63052 63053 64582 64628 64629 66989 66991 69705 69706 81168 81191 81192 81193 81194 81278 81279 81338 81339 81347 81348 81349 81351 81352 81353 81357 81360 81419 81523 81529 81546 81554 81560 93593 93594 93595 93596 93597 0018M 0227U 0228U 0229U 0230U 0231 U 0232U 0233U 0234U 0235U 0236U 0237U 0238U 0239U 0242U 0243U 0244U 0245U 0250U 0252U 0253U 0254U 0258U 0260U 0262U 0264U 0265U 0266U 0267U 0268U 0269U 0270U 0271 U 0272U 0273U 0274U 0276U 0277U 0278U 0279U 0280U 0285U 0286U 0287U 0288U 0289U 0290U 0291 U 0292U 0293U 0294U 0296U 0297U 0298U 0299U 0300U 0620T 0621T 0622T 0623T 0624T 0625T 0626T 0651T 0652T 0656T 0657T 0660T 0661T 0664T 0665T 0666T 0667T 0668T 0669T 0670T 0671T A2001 A2002 A2003 A2004 A2005 A2006 A2007 A2008 A2009 A2010 C1832 C9772 C9773 C9774 C9775 G2172 G2174 G2177 G2198 G2201 G2203 G2215 G2216 J1554 J1951 J7168 J7212 J7402 J9314 K1022 K1023 K1024 K1025 K1027 Q2054 Q2055 Q4199 Q4251 Q4252 Q4253 Q5122 Q5123 


These forms and other provider documents can be found under Provider Documents.

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

PA Archives

For detailed procedure code specific information regarding services, procedures and devices that require prior authorization, please reference the Current Prior Authorization Procedure Specific Listing. Please note that this list is updated on a quarterly basis. Please check the date on the form to ensure you are referencing the most up to date version.

Archive of Past Prior Authorization Procedure Specific Listings:

 

Personal Care Workers & PC Screening Tool

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. 

 

Personal Care Worker fillable form                  Personal Care Screening Tool              PC Screening Tool Instructions

 

These documents and others can also be found on the Prior Authorizations Documents page.

 

Services and Procedures Requiring Prior Authorization/Utilization Management Review

Prior authorization is required for:

  • Admission to a subacute facility (Skilled Nursing Facility, Long Term Acute Care Hospital, Inpatient Rehabilitation Facility)
  • Home health 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 

 

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Last Updated 5/19/22

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