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Prior Authorization Documents

This is the place for providers to find Prior Authorization-related forms and other documents. You can also find them on the Provider Documents page.

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Internal Guidance for Providers

Languages by County 2021 Excel Doc

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Provider Bulletin Dec 2022

EVV hard launch is May 1, 2023. Please review our bulletin for more information.

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InforMED News Brief #46 Wisconsin EVV

EVV for Medicaid-covered home health care services - requirement extended to 2024. Read more about Wisconsin EVV here.

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InforMED News Brief #44 PA Changes to Support NCQA Accreditation

iCare Prior Authorization will be implementing changes surrounding NCQA Accreditation. Please read more here.

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InforMED Provider eNewsletter Issue 4 - Q4 2022

As of October 1, 2022, ForwardHealth announced certification changes for substance abuse disorder (SUD) facilities. including the new allowable certification for adult residential integrated behavioral health stabilization services. And, EVV launch information.

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InforMED Provider eNewsletter Issue 3 2022

The Q3/Q4 iCare Provider eNewsletter has been emailed to iCare providers. Check it out here in case you missed it!

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InforMED News Brief #39 PA Specific Listing 6.1.22

iCare Prior Auth Procedure Specific Listing will have new codes added effective June 1, 2022.

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InforMED Provider eNewsletter Issue 3 2021

Provider news and updates to keep you Informed: iCare says goodbye to Tom Lutzow, the founder, President and CEO of iCare after 27 years; Behavioral Health and AOD Service Collaboration; Provider Add On Payment Program and the importance of reminding patients to have an Annual Wellness Visit; and so much more!

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Provider Bulletin Issue 1 - March 2021

In this issue: The difference between Claim Denial and Unclean Claims, Updates on Urinary Drug Screen Prior Auth, COVID-19 Vaccine Coverage, Model of Care Training, and iCare now offers EFT!

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InforMED News Brief #28 N95 Fit Testing Resources Survey

N95 Fit Testing Resources are now available for Assisted Living Staff. If you would like to receive an N95 fit testing kit, please complete and submit this brief survey as soon as possible.

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InforMED Provider eNewsletter Issue 1 2021

This issue shares all the ways the iCare website can be a resource for our providers. For education on claims, prior authorizations, COVID updates and more! This month shares a blog by iCare's VP of Accountable Care, Lisa Holden, about what medical professionals need to know about the CAHPS survey.

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Electronic Visit Verification Guide

A guide to assist you with claims submission and billing

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iCare Urine Drug Screen Policy

iCare Urinary Drug Screen prior authorization policy provides an overview of the minimum requirements to complete a urine drug screen (UDS) prior authorization (PA) request for Medicare, Medicaid, and BadgerCare Plus members.

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iCare Pulmonary Artery Monitoring-CardioMems Guidance for Providers

Evidence-based guidelines and industry best practices that iCare follows regarding CardioMems

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More Prior Authorization Documents

PA Request - Personal Care Worker (PCW) fillable form

Inpatient Notification Form

Independent Care Health Plan (iCare) must be notified of all inpatient stays within one (1) business day of the admission.

Procedure Specific Listing Q1-2023.pdf

Procedure Specific Listing Q1-2023.xlsx

iCare Prior Auth Request Form

Providers use this updated form to request a prior authorization

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.

Procedure Specific Listing Q2 2022 Excel

Procedure Specific Listing Q2 2022 PDF

Procedure Specific Listing Q2 2022 PDF

COVID 19 Claims & Coverage Guide

COVID 19 Webinar for Providers to understand iCare's Prior Authorization guidelines related to COVID claims

Part D Coverage Determination Request

PA Procedure Specific Listing Q1 2021

iCare Urine Drug Screen Guidance for Providers

iCare Urine Drug Screen Provider Education. As a standard benefit, all iCare members will receive 6 urine drug screens per year. For additional information about prior authorization, read this information document.

iCare Urine Drug Screen Policy

iCare Urinary Drug Screen prior authorization policy provides an overview of the minimum requirements to complete a urine drug screen (UDS) prior authorization (PA) request for Medicare, Medicaid, and BadgerCare Plus members.

iCare Pulmonary Artery Monitoring-CardioMems Guidance for Providers

Evidence-based guidelines and industry best practices that iCare follows regarding CardioMems

F02717-EVV-Live-In Worker ID fillable form

DHS Form: F02717-Electronic Visit Verification-Live-In Worker ID form

PCW HHC Message to Providers

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

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.

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

Procedure Specific Listing Q2 2020 Excel

Procedure Specific Listing Q2 2020 PDF

Procedure Specific Listing Q1 2020 PDF

Prior Authorization Procedure Specific Listing Q1 2020 Updated in pdf form

Procedure Specific Listing Q1 2020 Excel

Procedure Specific Listing Q1 2020 Excel

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.

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.

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.

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.

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.

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 - 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.

Prior Authorization Subacute Request Form

Prior Authorization Subacute Request Form

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.

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 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 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 Q1 2018 effective January 1 2018

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

PA-Testing for Drugs of Abuse

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

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

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.

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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.

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