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.
*Effective 8/15/25, the following codes have been removed from the PAL and no longer require pre-authorization:
DME/Orthotics:
A5500, A5503, A5504, A5506, A5507, A5513, E0185, E0186, E0950, E0974, E0990, E2205
E2209, E2220, E2323, E2359, E2366, E2367, K0017, K0069, K0072, K0606, K0739, 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
Cardiac Monitoring:
93241, 93242, 93243, 93244, 93246, 93247, 93248, 95700
Enteral Feeding Formula:
B4149, B4155, B4158, B4160, B4161