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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.

A Message from iCare’s Prior Authorization Department

 

 

New Prior Authorization Form

The PA department is changing 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. Please visit our Provider Documents page at:

https://www.icarehealthplan.org/Provider-Documents.htm to access the newest version of our Prior Authorization Request Form. 

Or click:  New Prior Auth Form to file a PA request.

We will no longer be accepting older versions of the Prior Authorization Form after March 6th, 2020.

 

 

New Prior Authorization Specific Listing

The Prior Authorization Department is releasing the Procedure Specific Listing for Q1 2020.  This listing was placed on the website February 5th, 2020 for providers to consult.  The Procedure Specific Listing for Q1 2020 will be effective March 6, 2020 and can be accessed at the link below:

https://www.icarehealthplan.org/Prior-Authorization.htm or by clicking

New Prior Auth Specific Listing/pdf    New Prior Auth Specific Listing/excel

Providers and staff will notice that the Prior Authorization Specific Listing for Q1 2020 looks significantly different than previous listings.  We have changed the formatting to make it more searchable and user friendly.  An excel version of this document is included, which will be able to be filtered by category, code, or description.  The PDF can be searched using the F5 option.

 

The following codes are being retired effective March 6, 2020:

0249T, 0340T, 0341T, 0357T, 0359T, 0360T, 0361T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0372T, 0374T, 0375T, 0377T, 0380T, 0399T, 0406T, 0407T, 19304, 81211, 81213, 81214, V5170, V5180, V5210, V5220, G0163, 36469, 90911, 97532, 64508, 64402, 64410, 64413, L7260, L7261

 

The following codes will be requiring Prior Authorization effective March 6, 2020:

0563T, 0564T, 0565T, 0566T, 0567T, 0568T, 0569T, 0570T, 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0581T, 0582T, 0583T, 0584T, 0585T, 0586T, 0587T, 0588T, 0589T, 0590T, 0591T, 0592T, 0593T, 99458, L2006, L8033, 90912, 95700, 0155U, 0156U, 0158U, 0159U, 0160U, 0161U, 0162U, 81277, 81307, 81308, 81309, 81522, 81542, 81552, 64451, 64454, 64624, 64625, 66987

Please reach out to the Prior Authorization Department with questions at 1-855-839-1032.

PA Archives

For detailed procedure code specific information regarding services, procedures and devices that require prior authorization, please reference the New 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:

Archive of Past Prior Authorization Request Form:

 

 

Personal Care Screening Tool

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Instructions and the form in both PDF and Microsoft Word format can be found on the Prior Authorization 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, please click here to Submit a CMS complaint form online 

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