Skip to Content
Main Content

Prior Authorization Documents

This is the place for providers to find Prior Authorization-related forms and other documents.

Pro Tip: You can also find them on the Provider Documents page, but we thought: Why not make it as easy for you as possible? 

Skip to Results Listing
Please wait while we gather your results.

Results Updated

30 Results Listed

Skip to Filters

2020 iCare Prior Auth Form

Providers use this updated form to request a prior authorization

Behavioral Health and AODA FAQs

This document answers frequently asked questions by providers about Behavioral Health and AODA as related to claims and prior authorization for treatment programs received by iCare members.

Chiropractor Claim Processing Guideline

This information is provided as a courtesy from iCare to assist you with claims submission and billing. This does not replace Forward Health and CMS Guidelines.

COVID 19 Claims & Coverage Webinar

COVID 19 Webinar for Providers to understand iCare's Prior Authorization guidelines during this time.

DME DMS Message to Providers

3/31/2020 Update from iCare Prior Authorization to providers of Durable Medical Equipment (DME) and Durable Medical Supplies (DMS)

General Subacute Communication to Providers

3/31/2020 Update from iCare Prior Authorization to providers including Subacute care, Long Term Acute Care (LTAC), Skilled Nursing Facilities (SNF) and Inpatient Rehabilitation facilities (IRF) providers.

iCare Personal Emergency Response System (PERS) Enrollment Form

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.

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

Medication Request Form

This form is used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is no suitable alternate available.

Part D Transition Process

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

PA-Testing for Drugs of Abuse

All outpatient drugs of abuse testing, both presumptive and definitive, require a prior authorization request.

PCW HHC Message to Providers

3/31/2020 Update from iCare Prior Authorization to Personal Care Workers and Home Health Care Providers.

Personal Care Screening Tool - Instructions

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here are instructions to do so.

Personal Care Screening Tool - MS Word Format

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here is the form in Microsoft Word format.

Personal Care Screening Tool (Form)

The Personal Care Screening Tool was developed to assist providers in determining the number of units to request for PA (prior authorization) of medically necessary personal care services that are to be provided by a PCW (personal care worker). Here is the form in PDF format.

Prior Authorization Procedure Specific Listing Q1 2017 effective January 1 2017

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q1 2018 effective January 1 2018

This Procedure provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage.

Prior Authorization Procedure Specific Listing Q3 2017 effective July 2017

This Procedure provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q3 2018 effective July 15 2018

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q3 2019 effective July 19 2019

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Requirements - In Home Meals

In-home meal service is provided by iCare as a supplemental Medicare benefit to members immediately following surgery or an inpatient hospital stay, for a temporary duration when ordered by a practitioner.

Prior Authorization Subacute Request Form

Prior Authorization Subacute Request Form

Procedure Specific Listing Q1 2020 Excel

Procedure Specific Listing Q1 2020 Excel

Procedure Specific Listing Q1 2020 PDF

Prior Authorization Procedure Specific Listing Q1 2020 Updated in pdf form

Procedure Specific Listing Q2 2020 REV 5.13.20 Excel

Procedure Specific Listing Q2 2020-Updated 5.13.20 Excel

Procedure Specific Listing Q2 2020 REV 5.13.2020 PDF

Procedure Specific Listing Q2 2020 - revised and effective 5.13.20

Psych Testing Guidelines

Behavioral health providers use this form to provide information in conjunction with the prior authorization request about a member's psychological case background, and information relating to referred testing for a member.

Leaving iCareHealthPlan.org

By clicking this link, you may be leaving the iCareHealthPlan.org website. Independent Care Health Plan (iCare) only provides these links and pointers for your information and convenience. When you select a link to an outside website, you are leaving the www.iCareHealthPlan.org website.

ProceedCancel