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
- Select durable medical equipment
- Select procedures
- Outpatient physical, occupational, and speech therapy & cardiac and pulmonary rehabilitation
- 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 determination of a prior authorization.
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.