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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 2/15/23, the following codes will be added to the list requiring PA:

A2014, A2015, A2016, A2017, A2018, A4596, C9098, E0183, J0739, J1302, J1306, J1551, J1932. J2356, J2777, J2779, J2998, J3299, J9274, J9298, J9331, J9332, Q2056, T1032, T1033

And removing the PA requirements for:

92603, 92604, 92626, 81420, 92610, 92611, 76801, 95700, 93241-93248, V2623, V2624, V2625, V2626

(Please be aware that the current pdf and excel linked above do not include these updates, but we are working diligently to publish them as quickly as possible.)


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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