Authorization Requirements

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.

Notification of all inpatient admissions (medical and behavioral) must be faxed to iCare (414-231-1075), using the Inpatient Medical PA Form or the Behavioral Health PA 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.

iCare does not require prior authorization (PA) for the first 35 outpatient therapy visits per calendar year. Prior authorization is required for outpatient Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services that exceed this threshold.

Initial Prior Authorization Requests

iCare authorizes outpatient therapy based on the number of visits requested. To complete the clinical review and determine medical necessity, providers must include all CPT codes anticipated to be billed on the Prior Authorization Request form.

To support the medical necessity review, please submit:

• Completed Prior Authorization Request form
• Therapy evaluation
• Plan of care
• Signed physician prescription/order

Comprehensive clinical information is necessary to establish the member's functional status, rehabilitation potential, and expected benefit from the requested services. 

Outpatient therapy services are authorized based on medical necessity, as defined in Wis. Admin. Code § DHS 101.03(96m). Providers are responsible for ensuring that services are covered under the applicable Medicare or Medicaid benefit.

Backdating of Initial Authorizations

If a PA request is received within 14 calendar days of the initial therapy evaluation, an approved authorization may be backdated to the evaluation date.

Authorization requests submitted more than 14 calendar days after the initial evaluation date will not be retroactively authorized.

Continuing Therapy Requests

Additional therapy visits may be requested when a member requires services beyond the visits previously authorized.

For all continuing therapy requests:

• Prior authorization must be obtained before services are rendered.
• Requests for additional visits will not be backdated.
• Providers must submit:
  • Completed Prior Authorization Request form
  • Clinical documentation supporting the need for ongoing therapy services

Authorization Determinations

Prior authorization requests are approved for varying timeframes based on the clinical documentation submitted.

When a request is approved, providers will receive a PA decision notice that includes:

• Authorized services
• Approved number of visits
• Authorization start date
• Authorization end date

Services may be provided beginning on the approved start date.

Important: An approved authorization indicates that the requested service has been approved; however, approval may not include every CPT code submitted. Providers are encouraged to carefully review authorization determinations to verify the services authorized and applicable authorization dates.

Referrals

A referral is required for:

• Requests for a second opinion or additional opinions
• Services provided by a non-participating provider outside of the member’s home state

To request authorization for a referral, submit a completed Prior Authorization Request form along with supporting clinical documentation that demonstrates the medical necessity of the requested referral.

iCare 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

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.

iCare requires providers to submit the Urine Drug Screen (UDS) Testing Prior Authorization Request Form, as well as additional documentation to support the level of service requested, for the following Presumptive & Definitive Drug Test codes:

• Presumptive Drug Test codes: 80306, 80307.
• Definitive Drug Test codes: G0481, G0482, G0483, G0659.

No Prior Authorization will be required for the following Drug Test codes: 80305, G0480.

The member's medical record must contain documentation that fully supports the medical necessity for services rendered.

This documentation includes, but is not limited to, relevant medical history, physical examination, risk assessment, and

results of pertinent diagnostic tests or procedures. The medical record must include:

• Signed and dated member-specific order for each ordered drug test that provides sufficient information to substantiate each testing panel component performed ("standing orders," "custom profiles," or "orders to conduct additional testing as needed" are insufficiently detailed and cannot be used to verify medical necessity)

• A copy of the test results
• Rationale for ordering a definitive drug test for each drug class tested
• If a direct-to-definitive drug test is ordered, documentation supporting the inadequacy of presumptive drug testing

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

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