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Authorization Requirements

 

Prior Authorization Requirements

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The iCare Prior Authorization department would like to share our developing processes for Personal Care Workers and Home Health Care providers on Electronic Visit Verification (EVV) for 2021. The current soft launch (hard launch is yet to be determined) will allow us to implement the Wisconsin Department of Health Services (DHS) guidance.

Please note: iCare does not require EVV for live-in caregivers, however the provider must supply a completed EVV Live-In Worker Identification form, F-02717, at the time of authorization for all live-in workers. Failure to submit required documentation following the DHS Hard Launch date will result in a denial of authorization for a live-in worker. iCare encourages providers to begin submitting the F-02717 form for live-in workers during the Soft Launch period to avoid future PA denials after Hard Launch.

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  Home Health & Hospice

All PA requests for home health and hospice services must include a signed physician order and plan of care as well as the initial in home evaluation for review.

All PA requests for home health and hospice services must be submitted to iCare within 14 calendar days from the start of care. iCare will not retro authorize any services submitted after the 14th day.

Ongoing services must be requested and will continue to require an updated signed physician’s order/plan of care. For ongoing services, all PA requests are required to be submitted within 14 days after the expiration date of the previous authorization.

All late PA requests for home health and hospice services will be reviewed for medical necessity starting from the date the request was received by iCare.

iCare prior authorizes home health and hospice services for the following timeframes:

Personal Care Worker-180 days or 26 weeks

Skilled Nursing-60 days or 9 weeks

PT/OT/SLP/MSW-60 days or 9 weeks

Hospice-60 days

  Inpatient Notification

Notification of all inpatient admissions (medical and behavioral) must be faxed to iCare (414-231-1075), using the Inpatient Notification Request Form, within one (1) business day of admission. This allows iCare to initiate discharge planning. Hospitals must ALWAYS notify iCare of all inpatient admissions whether they are elective or emergent.

  Outpatient PT, OT, ST, and Cardiac & Pulmonary Rehabilitation

Prior Authorization is required for all outpatient therapy services including PT, OT, and SLP.

iCare authorizes outpatient therapy by number of visits; however, the CPT codes that the provider anticipates billing MUST be listed on the prior authorization request form in order tocomplete the clinical review and determine medical necessity.

Comprehensive information about the member helps to establish the functional potential of the member and forms the basis for determining whether the member will benefit from the requested services. Please submit the Prior Authorization Request form along with the completed therapy evaluation, plan of care, and signed physicians prescription for review to determine if the service is medically necessary.

Outpatient therapy will be authorized based on medical necessity. Services that are medically necessary are defined under Wis. Admin. Code § DHS 101.03(96m). The provider is responsible to assure that the services provided are covered under the Medicare or Medicaid benefit, whichever applies.

An approved PA request will be backdated to the initial date of the evaluation if the PA request is received within 14 calendar days of the initial therapy evaluation. iCare will not retro authorize any authorization requests submitted beyond the 14 calendar days of the initial evaluation.

Continuing therapy requests may be requested when the member's need for therapy services is expected to exceed the maximum allowable treatment days authorized.

For continuing therapy requests, prior authorization must be obtained. PA requests for ongoing therapy will not be backdated. To request additional visits, please submit the completed Prior Authorization Request form, as well as clinical documentation to support medical necessity for ongoing therapy services.

PA requests are approved for varying periods of time based on the clinical justification submitted. The provider receives a copy of a PA decision notice when a PA request for a service is approved. Providers may then begin providing the approved service on the start date given.

An approved request mean that the requested service, not necessarily by code, was approved. Providers are encouraged to review approved PA requests to confirm the services authorized and confirm the assigned start and end dates.

All claims for services are subject to the coverage and medical necessity guidelines provided by Medicare and Medicaid.

Medicare Guidelines for Outpatient Physical and Occupational Therapy Services can be found here.

Medical Guidelines can be found here.

  Personal Care Worker

iCare will now grant authorizations for PCW services for up to 1 year at a time to better align with ForwardHealth.  Members who receive at least 2 hours per day of care will receive shorter authorizations per iCare discretion.  Providers should use the new PA form designated for PCW services:

PA-Personal Care Worker fillable form

PC Screening Tool

Authorization requirements:

All initial and annual recertification requests must also include a copy of the signed MD/DO/NP order (CMS-485); recent history/physical or office notes, Personal Care Screening Tool (PCST), and Google Maps or Mapquest if travel time is being requested.  Personal Care agencies are required to meet all Electronic Visit Verification (EVV) requirements as outlined in the ForwardHealth Policy.  iCare does not require EVV for live-in caregivers, however the provider must supply a completed EVV Live-In Worker Identification form, F-02717, at the time of authorization for all live-in workers. Failure to submit required documentation will result in a denial of authorization for a live-in worker.

Third party assessment information:

iCare reserves the right to conduct third party assessments for every new and ongoing request. It is the responsibility of each provider to educate the member on this process since iCare can deny services if the third party assessment is not completed.  Allocation of hours will be based on the third party assessment; the provider’s assessment and review of all pertinent clinical documentation. 

Ongoing services:

Recertification requests are required to be submitted within 30 days after the expiration date of the previous authorization.  Providers may choose to submit authorizations more frequently than once a year due to their own internal policies.  However, new PCSTs should only be submitted once a year unless there has been a significant and chronic change of condition that warrants additional time.  If the ongoing PA request does not align with iCare’s previous decision, and there has been no change in member’s condition, then the authorization request will be changed to reflect what member has been approved for.  

Acute change of condition:

If the member has had an acute change of condition (i.e. recovery from surgery), an additional authorization will be granted for 90 days to supplement the extra hours, and then hours will revert back to iCare’s previous decision.  All requests for increased services must include a signed physicians order and clinical documentation to support the increase. Because iCare will only conduct third party assessments for an acute change of condition on a case by case basis, it is the obligation of the provider and physician to determine the additional hours that are needed.

  Personal Emergency Response System (PERS)

In-home Personal Emergency Response System (PERS) is provided by iCare as a supplemental Medicare benefit. PERS is indicated for personal use for members with medical conditions resulting in functional limitations or incapacitation that prevent the member from using other means of summoning assistance in an emergency.

To request prior authorization for the Personal Emergency Response System , please submit the iCare Personal Emergency Response System (PERS) Enrollment Form.

Practitioner Requirements to Support PERS Coverage

The physician or treating practitioner must submit a signed doctor’s order for the PERS. A completed PERS referral form that is signed by the physician or treating practitioner is acceptable.

All PA requests and supporting documentation are received through iCare’s Prior Authorization (PA) fax mailbox (414- 231-1026). The PA staff will process the prior authorization requests according to internal iCare policy, PA-001 (Outpatient Skilled Services, Durable Medical Equipment, and Procedures).

Supplier Requirements for PERS

The supplier must obtain prior authorization approval before dispensing the PERS and related equipment.

Claims codes (required for claims processing)

S5160 – Installation/Testing/Activation/Education = $0

S5161 – (U1) Home Based Landline PERS = $24/mo.

S5161 – (U2) Home Based Cellular PERS = $29/mo.

S5161 – (U3) Home Based Fall Detection Pendant = $5/mo.

S5161 – (U4) Extra Home Based Pendant = $5/mo.

S5161 – (U6) Lockbox for Spare Key Upon Request = $0 (complimentary)

S5161 – (U7) Smoke Detector (24/7/265 monitored) = $10/mo.

S5161 – (U8) Special Adaptive Strobe for Hearing Impaired = $10/mo.

S5161 – (U9) Special Adaptive Switch for Physically Impaired = $10/mo.

S5161 – (C1) Numera Libris w/ GPS & Fall Detection = $36.95/mo.

S5161 – (C6) FreeUs Belle+ w/ GPS & Fall Detection = $36.95/mo.

S5161 – (C5) FreeUs Belle w/ WiFi Geo Location Service = $32.95/mo.

Workflow for benefit authorization

1. Member need for PERS service is identifiedCare Management

a. Care Management teams may identify a member through scheduled assessments and/or at the time of discharge from an inpatient facility and/or through iCare care review meetings (e.g., high risk staffing, chronic disease management staffing, grand rounds, RAP reviews, etc.)

Prior authorization nursing staff may identify members whom they feel would benefit from the PERS service and will coordinate with the members’ care management staff to discuss.

b. Members’ provider team\

Providers may recommend members receive this service based on face-to-face office visits or inpatient admissions. Providers may be aware of this benefit provided by iCare as they will have access to iCare’s provider website and those who have email addresses will have access to blast emails. iCare’s provider newsletters feature the enhanced benefits in occasional quarterly publications.

2. Initiation of prior authorization process for member’s who would benefit from PERS:

a. Care management staff will fax or email the PERS referral form to the member’s provider, completing all fields, if possible

b. Providers will submit a prior authorization request, including completed PERS referral form or signed physician’s order, directly to iCare’s PA department.

3. Submission of the Prior Authorization request and subsequent organization determination

a. Following receipt of the prior authorization request, the PA RN assigned to its review will determine if all necessary documents are present and will collaborate with the providers’ offices as needed.

b. iCare has 14 calendar days from the receipt of the PA request to the date the request is determined. If information requisite to determine the request is not provided by day 14, iCare may, at its discretion, request a date extension of 14 calendar days to provide time to collect missing data

c. If the member does not meet medical necessity criteria, iCare will issue a benefit denial, notifying the member, the ordering provider and the vendor and providing appeal rights.

d. If the member meets medical necessity criteria, iCare will issue the provider authorization notification to the ordering provider and the vendor and issue an approval letter to the member.

Authorization will be given for one calendar year at a time. The care team will identify members that continue to require the PERS device and are not currently at a Subacute Nursing Facility or Assisted Living Facility. The care team will re-initiate the process by completing a new PERS referral form and submitted it to the Prior Authorization Department.

  Referrals

Referrals are required for:

  • Second (or additional) opinions
  • Referrals to non-participating providers outside of the member’s home state

To request prior authorization for a referral, please submit the Prior Authorization Request form as well as clinical documentation to support medical necessity for the requested referral.

  Solid Organ Transplant Criteria

Independent Care Health Plan Solid Organ Transplant Criteria

Prior authorization is granted for a period of six months. Prior to the six-month time frame of this authorization, if the member remains active on the transplant list and continues to meet UNOS criteria, please resubmit updated clinical information with new prior authorization request. If at any time during the six-month authorization time period either the member or the institution no longer meets UNOS/CMS criteria, this authorization will be denied effective on the day of loss of eligibility.

  1. Presence of advanced chronic organ disease and end-stage disease, specific to the requested organ transplant; e.g., for kidney transplant, end-stage disease typically refers to stage 4-5 CKD, although individual circumstances are considered; for liver transplants, end-stage disease is usually indicated by irreversible pathology including cirrhosis
  2. Medical indications of severity of illness, as applicable to the type of organ transplant; e.g., Glomerular filtration rate of less than 30 mL/minute for kidney transplants or serum ammonia levels for liver transplants
  3. Interest in transplant following appropriate informed consent about survival and quality of life with and without a transplant, including the responsibility of strict adherence to medication and treatment plans after transplant, as well as palliative care options
  4. Presence of comorbid conditions such as: malignancy (cancer), heart disease, peripheral vascular disease, chronic liver disease, chronic lung disease, obesity (determined by Body Mass Index), infections (chronic viral infections, bacterial colonization, etc.), and other similar chronic conditions that jeopardize the safety of patient before, during, and after transplant surgery
  5. Non-compliance with medications and treatment regimen that will directly impact the survival of the transplanted organ. 
    *Patients who have clinical documentation suggesting non-compliance will require documentation from a psychology/psychiatry transplant team member that the patient is still eligible for transplant with discussion of any barriers to compliance and recommended resolutions, as applicable
  6. Active or recent history of addiction disease including, but not limited to, alcohol dependence, use of illegal drugs including heroin, cocaine, crack cocaine, Ecstasy, methamphetamine, bath salts, and amphetamines.
    ​​​​​​​*Patients presenting with active addiction disease or history of active use during the past 6 months require at least a 6-month clean period to include documentation of urine or blood drug testing results
  7. Cognitive impairment: patients who have a history of mental illness or who develop symptoms of new onset mental illness or neurologic injury will be evaluated for their ability to understand the risks involved in transplant, social supports needed to be successful after transplant, and if they have the ability to be adherent to treatment regimen given their social support system and capacity to understand their health care needs
  Subacute Facilities

All sub-acute facility (skilled nursing facility, inpatient rehab facility, long term acute care hospital) admissions require prior authorization. All prior authorization requests and clinical documentation to support medical necessity must be faxed to iCare, using the Subacute Facilities Prior Authorization Request form, and approved prior to the member's admission to the facility. Prior authorization must be submitted at least 24 hours prior to the date of admission. iCare completes concurrent reviews on all subacute facility prior authorization requests.

  Transcutaneous Electrical Nerve Stimulation (TENS)

Prior Authorization: Transcutaneous Electrical Nerve Stimulation (TENS)

Date in service: 12/31/2015

Date reviewed: 01/12/2018

DOCUMENTATION REQUIREMENTS

A transcutaneous electrical nerve stimulator (TENS device) requires the following documentation in order for Independent Care Health Plan (iCare) to evaluate medical necessity:

A physician’s medical order for a TENS device

The physician ordering the TENS device and related supplies must be the treating physician for the disease or condition justifying the need for the TENS device

For coverage of a purchase, the physician must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the device over a long period of time. Supportive criteria for this must be included in provided documentation

Medical records documenting a face-to-face visit with the physician ordering the TENS device that includes the medical, behavioral, and social interventions used in treating the member for their disease or condition

Medication lists, support services recommended/in place, psychiatry notes documenting treatment plans, etc.

The documented history and physical examination and assessment must support the diagnosis and the treatment plan.

The documentation should also include the causes and clinical effects of pain including an assessment of the ability of the individual to perform activities of daily living.

The impact of previously attempted interventions for chronic pain should be documented.

Additional clinical documentation of multidisciplinary approaches used in treating the member for their disease or condition

Occupational therapy, physical therapy, pain management procedures and/or pain contracts, complementary and alternative medicine modalities used/recommended, etc

Psychosocial evaluation, including information about the presence of symptoms of depression, anxiety, or anger; psychiatric disorders, personality traits or states; and coping mechanisms

MEDICAL NECESSITY REQUIREMENTS

A TENS device it covered for the treatment of beneficiaries meeting the following requirements:

Acute post-operative pain
TENS is covered for acute post-operative pain. Coverage is limited to 30 days (one month rental) from the date of surgery
Members not meeting ALL of the aforementioned criteria will be denied a TENS device based on lack of medical necessity

Chronic pain (other than low back pain)
TENS devices are covered for chronic, intractable pain other than chronic low back pain when ALL of the following criteria are met:

The pain must be documented to have been present for at least 3 continuous months, AND

The individual must be actively participating in multimodal treatments for chronic pain, including, but not limited to: physical therapy or occupational therapy; regularly scheduled physical activity (e.g., swimming, yoga); massage therapy; acupuncture or other CAM modalities; psychological, psychiatric, and/or pharmaceutical treatments for chronic pain, AND

Other appropriate pain treatments must have been tried and failed, AND

The chronic condition documented must be of a type that is documented in the peer-reviewed medical literature to respond to TENS therapy

Chronic low back pain (CLBP)
TENS therapy for CLBP is only covered when ALL of the following criteria are met:

The beneficiary has one of the following diagnoses listed in the diagnosis section below, AND

The beneficiary is enrolled in an approved clinical study that meets all of the requirements set out in NCD §160.27 (CMS Internet Only Manual 100-3, Chapter 1).2 Refer to the APPENDICES section for additional information about approved clinical studies, AND

The beneficiary has one of the following diagnoses:

LUMBOSACRAL ROOT LESIONS NOT OTHERWISE CLASSIFIED

SACROILIITIS NOT OTHERWISE CLASSIFIED

LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY

SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION

DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY

DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION

POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION

SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

LUMBAGO

SCIATICA

THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

ACQUIRED SPONDYLOLISTHESIS

NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED

CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION

SPONDYLOLISTHESIS CONGENITAL

CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY

CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN

SACROILIAC (LIGAMENT) SPRAIN

LUMBAR SPRAIN

INJURY TO LUMBAR NERVE ROOT

Members not meeting ALL of the aforementioned criteria will be denied a TENS device based on lack of medical necessity.

GENERAL REQUIREMENTS FOR CHRONIC PAIN AND CLBP

A 4-lead TENS device may be used with either 2 leads or 4 leads, depending on the characteristics of the beneficiary's pain. If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the beneficiary’s needs.

SUPPLY COVERAGE REQUIREMENTS

Separate allowance will be made for replacement supplies when they are reasonable and necessary and are used with a covered TENS. Usual maximum utilization is:

2 TENS leads - a maximum of one unit of A4595 per month

4 TENS leads - a maximum of two units of A4595 per month

If the use of the TENS device is less than daily, the frequency of billing for the TENS supply code should be reduced proportionally.

Replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary.

A conductive garment (E0731) used with a TENS device is rarely reasonable and necessary, but is covered only if ALL of the following conditions are met:

a. It has been prescribed by the treating physician for use in delivering covered TENS treatment, AND

a. ONE of the medical indications outlined below is met:
The beneficiary cannot manage without the conductive garment because:

There is such a large area or so many sites to be stimulated AND the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires, OR

The beneficiary cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires, OR

The beneficiary has a documented medical condition, such as skin problems, that preclude the application of conventional electrodes, adhesive tapes, and lead wires, OR

The beneficiary requires electrical stimulation beneath a cast to treat chronic intractable pain.

A conductive garment is not covered for use with a TENS device during the trial period unless:
The beneficiary has a documented skin problem prior to the start of the trial period; AND the TENS is reasonable and necessary for the beneficiary.

If the criteria above are not met for E0731, it will be denied as not reasonable and necessary.

Reimbursement for supplies is contingent upon use with a covered TENS device. Claims for TENS supplies provided when there is no covered TENS device will be denied as not reasonable and necessary.

REFILL REQUIREMENTS

For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order.

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a 3-month quantity at a time.

CODING REQUIREMENTS

  • E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
  • E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, multiple nerve stimulation
  • E0731 Form fitting conductive garment for the delivery of TENS (with conductive fibers separated from the patient’s skin by layers of fabric)

AFFORDABLE CARE ACT (ACA) 6407 REQUIREMENTS

ACA 6407 contains provisions that are applicable to certain specified items:

  • E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION
  • E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION
  • E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)

These items require an in-person or face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A Written Order Prior to Delivery (WOPD) is required.

REFERENCES:

  1. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. 1997 Apr (revised 2010 Apr). NGC:007951 http://www.guideline.gov/content.aspx?id=23845&search=chronic+pain
  2. CMS National Coverage Determinations: (NCD): Transcutaneous Electrical Nerve Stimulation for Acute Post-Operative Pain, for Chronic Low Back Pain, and Transcutaneous Electrical Nerve Stimulators (10.2, 160.27, 280.13, respectively) (All Active policies).
  Urine Drug Screen

Independent Care Health Plan Urine Drug Screen Prior Authorization Requirements

Effective 4/1/2021, iCare has updated its prior authorization policy for Testing for Drugs of Abuse. 

Standard Benefit

  • As a standard benefit, all iCare members will receive 6 urine drug screens per year
  • No clinicals or order needed, simply fill out the PA form on the icare website at https://www.icarehealthplan.org/Prior-Auth-Forms
  • PA must be submitted annually to renew this benefit
  • iCare will accept retro authorization requests for up to 14 days after the first UDS was administered
  • PA for presumptive (over the benefit level of 6) and definitive tests (regardless of indication for treatment) may be submitted for 1 year intervals

For more information, including Indications for Treatment, Overages, Definitions and References, review the full Urine Drug Screen Provider Education

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