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This is a central location providers use to find forms, publications, reference manuals and other documents essential to providing care for iCare members. Filters make it easy to find exactly what you're looking for. 

To locate a Medicare Advantage coverage policy referenced in a letter you received, you can type the four-digit policy number (for example WI.PA-1223) in the Keywords search box below. iCare has also prepared some FAQs for Medicare Advantage coverage policies.

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Provider Documents that match your criteria:

2023 Medicare Payment Provisions-Dental

Document Types
  • Policies and Guidelines

2023 Provider Access Survey Results

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Provider Forms
  • Provider News/Bulletin
Plans
  • ALL

2024 Comprehensive Formulary - updated 12/1/2024

Document Types
  • Formulary/ Pharmacy Documents
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2024 Part C 5-Star Performance Measures

Document Types
  • Internal Guidance for Providers
  • Plan Information
  • Policies and Guidelines
  • Programs
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2024 Part D Prior Authorization Criteria - updated 12/1/24

Document Types
  • Formulary/ Pharmacy Documents
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2024 Step Therapy Prescription Drug Criteria - updated 12/1/2024

Document Types
  • Formulary/ Pharmacy Documents
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2025 AEP iCare Medicare Provider Directory Northeast

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories
Plans
  • iCare Medicare Plan

2025 AEP iCare Medicare Provider Directory Northwest

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories
Plans
  • iCare Medicare Plan

2025 AEP iCare Medicare Provider Directory Southcentral Southwest

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories
Plans
  • iCare Medicare Plan

2025 AEP iCare Medicare Provider Directory Southeast

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories
Plans
  • iCare Medicare Plan

2025 AEP Oct iCare Family Care Provider Directory

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories
Plans
  • iCare Family Care Partnership

2025 Comprehensive Formulary

Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2025 iCare FCP Annual Notice of Change

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Family Care Partnership

2025 iCare FCP Evidence of Coverage

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Family Care Partnership

2025 iCare FCP Summary of Benefits

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Family Care Partnership

2025 iCare Medicare Annual Notice of Change

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Medicare Plan

2025 iCare Medicare Evidence of Coverage

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Medicare Plan

2025 iCare Medicare Summary of Benefits

Document Types
  • Benefit Information
  • Plan Information
Plans
  • iCare Medicare Plan

2025 Part D Prior Authorization Criteria

Document Types
  • Formulary/ Pharmacy Documents
  • Internal Guidance for Providers
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2025 Stars Rating

Document Types
  • Plan Information
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

2025 Step Therapy Rx Drug Criteria

Document Types
  • Formulary/ Pharmacy Documents
  • Internal Guidance for Providers
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

Affiliation Change Form

Document Types
  • Provider Forms

Ambulance Claims

Document Types
  • Claims
  • Internal Guidance for Providers
  • Provider News/Bulletin

ARPA - Family Care Partnership Update 1 21 22

Document Types
  • Policies and Guidelines

ARPA Procedure Code list 01 09 2022.pdf

Document Types
  • Policies and Guidelines

BadgerCare Plus & Medicaid Mom & Baby Program

Document Types
  • Health Education
  • Programs
Plans
  • iCare BadgerCare Plus

BC+ SSI Measure Year 2024 P4P Quality Measures

Document Types
  • Health Education
  • Internal Guidance for Providers
  • Policies and Guidelines
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Behavioral Health and AODA FAQs

Document Types
  • Behavioral Health
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

Borrower Paycheck Protection Program Application

Document Types
  • Provider News/Bulletin

Civil Rights Compliance Plan Form

Document Types
  • Applications

Claim Form - LTC Professional - updated 1/2024

Document Types
  • Claims
  • Provider Forms
Plans
  • iCare Family Care Partnership

Claim Form - LTC Residential - updated 11/2024

Document Types
  • Claims
Plans
  • iCare Family Care Partnership

Clean Claim Requirements (CMS 1500)

Document Types
  • Claims
Plans
  • ALL

Clean Claim Requirements (UB-04)

Document Types
  • Claims
Plans
  • ALL

COVID 19 Claims & Coverage Guide

Document Types
  • Claims
  • Prior Authorization

Cultural Competency Training 1

Document Types
  • Provider News/Bulletin

Cultural Competency Training 2

Document Types
  • Health Education
  • Policies and Guidelines

Demographic Change Form

Document Types
  • Provider Forms

EFT Enrollment Check List

Document Types
  • Claims

Electronic Visit Verification (EVV) Guide

Plans
  • iCare BadgerCare Plus
  • iCare Family Care Partnership
  • iCare Medicaid SSI
  • iCare Medicare Plan

Electronic Visit Verification Guide

Document Types
  • Internal Guidance for Providers

Enhanced Ambulatory Patient Grouping Announcement

Document Types
  • Policies and Guidelines
  • Provider News/Bulletin

F02717-EVV-Live-In Worker ID fillable form

Document Types
  • Prior Authorization
  • Provider Forms

FCP Provider Reference Manual

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Provider Forms
Plans
  • iCare Family Care Partnership

FDR Attestation Form

Document Types
  • Policies and Guidelines
  • Provider Forms
Plans
  • ALL

Fraud Waste and Abuse Training

Document Types
  • Policies and Guidelines

General Subacute Communication to Providers

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

Hearing Claims

Document Types
  • Claims

Home Care Medical Outlines New CMS Documentation Initiative

Document Types
  • Policies and Guidelines
  • Provider News/Bulletin

Home Health Claims

Document Types
  • Claims

Hospice Claims

Document Types
  • Claims

HPMS Memo NPPES Provider Directory 1-3-2020

Document Types
  • Policies and Guidelines
Plans
  • ALL

iCare Coverage Criteria FAQ Document

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

iCare Model of Care Guide

Document Types
  • Policies and Guidelines

iCare Prior Auth Request Form

Document Types
  • Prior Authorization
  • Provider Forms
Plans
  • ALL

iCare Provider Portal Registration Guide

Document Types
  • Policies and Guidelines

iCare Provider Portal User Guide

Document Types
  • Claims
  • Policies and Guidelines

iCare Provider Reference Manual - Medicare & Medicaid

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Provider Forms
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
  • iCare Medicare Plan

iCare Pulmonary Artery Monitoring-CardioMems Guidance for Providers

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Prior Authorization

iCare Remit Reason Codes

Document Types
  • Claims
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

iCare Residential Availability Form

Document Types
  • Provider Forms
Plans
  • iCare Family Care Partnership

iCare Urine Drug Screen Guidance for Providers

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

iCare Urine Drug Screen Policy

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

iCare webinar-04-2021-Promoting Excellence in Assisted Living slides.pdf

Document Types
  • Programs
Plans
  • iCare Family Care Partnership

Inpatient Notification Form

Document Types
  • Policies and Guidelines
  • Prior Authorization
  • Provider Forms
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
  • iCare Medicare Plan

Languages by County 2021 Excel Doc

Document Types
  • Health Education
  • Internal Guidance for Providers

Limited English Proficiency Training

Document Types
  • Policies and Guidelines
  • Provider Forms

Long Term Care (LTC) Claims

Document Types
  • Claims

LTC Residential Claim Submission via iCare Provider Portal How to Guide

Document Types
  • Claims
  • Internal Guidance for Providers
Plans
  • iCare Family Care Partnership

Measure Year 2024 Medicaid SSI BC+ P4P Measures and Weights

Document Types
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Programs
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Medicaid BadgerCare Appeal Language 2_8_24

Document Types
  • Claims
  • Internal Guidance for Providers
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Medicaid FCP and SSI Appeal Language 2_8_24

Document Types
  • Claims
  • Internal Guidance for Providers
Plans
  • iCare Family Care Partnership

Medicare Basic Dental Benefit Exception Guidelines 2024

Document Types
  • Claims
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Provider Forms
Plans
  • ALL

Medicare Star Ratings

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

Medication Reconciliation Post-Discharge Form

Document Types
  • Formulary/ Pharmacy Documents
  • Provider Forms
Plans
  • ALL

Medication Request Form

Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization
  • Provider Forms
Plans
  • ALL

Member Handbook Changes Summary Template Draft for MCOs

Document Types
  • Grievances & Appeals
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

New Provider Education - updated 09.2024

Document Types
  • Claims
  • Internal Guidance for Providers
  • Policies and Guidelines
  • Provider News/Bulletin
Plans
  • ALL

Non-Discrimination Notice

Document Types
  • Policies and Guidelines
Plans
  • iCare BadgerCare Plus
  • iCare Family Care Partnership
  • iCare Medicaid SSI
  • iCare Medicare Plan

Notice of Privacy Practices

Document Types
  • Policies and Guidelines

Ombuds for BadgerCarePlus and SSI Medicaid HMO Members

Document Types
  • Claims
  • Grievances & Appeals
Plans
  • ALL

Ombuds Information (Hmong)

Document Types
  • Health Education
  • Policies and Guidelines

Ombuds Information (Spanish)

Document Types
  • Health Education
  • Policies and Guidelines
Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

PA Request - Personal Care Worker (PCW) fillable form

Document Types
  • Prior Authorization
  • Provider Forms

Part D Coverage Determination Request

Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization
  • Provider Forms
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

Part D Redetermination Request - Family Care Partnership

Document Types
  • Formulary/ Pharmacy Documents
  • Grievances & Appeals
  • Provider Forms
Plans
  • iCare Family Care Partnership

Part D Redetermination Request - Medicare

Document Types
  • Formulary/ Pharmacy Documents
  • Grievances & Appeals
  • Policies and Guidelines
Plans
  • iCare Medicare Plan

Part D Transition Process

Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

PCW HHC Message to Providers

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • ALL

PCW Institutional Outpatient Claim Submission via iCare Provider Portal How To Guide

Document Types
  • Claims
  • Internal Guidance for Providers
Plans
  • iCare BadgerCare Plus
  • iCare Family Care Partnership
  • iCare Medicaid SSI

PCW vs. LTC Guide

Document Types
  • Claims

Personal Care Screening Tool - Instructions

Document Types
  • Policies and Guidelines
  • Prior Authorization
  • Provider Forms
Plans
  • iCare Family Care Partnership

Personal Care Screening Tool - MS Word Format

Document Types
  • Applications
  • Prior Authorization
  • Provider Forms
Plans
  • iCare Family Care Partnership

Personal Care Screening Tool (Form)

Document Types
  • Policies and Guidelines
  • Prior Authorization
  • Provider Forms
Plans
  • iCare Family Care Partnership

Policy - Caregiver Background Check

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

Policy - Clinical Practice Guidelines

Document Types
  • Health Education
  • Internal Guidance for Providers
  • Policies and Guidelines
Plans
  • ALL

PPP Borrower Information Fact Sheet

Document Types
  • Provider News/Bulletin

Practitioner Attestation

Document Types
  • Applications
  • Policies and Guidelines
  • Provider Forms

Prescriber Enrollment Update Notice from CMS

Document Types
  • Formulary/ Pharmacy Documents
  • Policies and Guidelines
  • Provider News/Bulletin

Prior Authorization Requirements - In Home Meals

Document Types
  • Policies and Guidelines
  • Prior Authorization

Procedure Specific Listing Q1-2023.pdf

Document Types
  • Prior Authorization

Procedure Specific Listing Q1-2023.xlsx

Document Types
  • Prior Authorization

Provider Application - Durable Medical Equipment

Document Types
  • Applications
  • Claims
  • Provider Forms
Plans
  • ALL

Provider Application - Long Term Care

Document Types
  • Applications
Plans
  • iCare Family Care Partnership

Provider Application - Primary and Acute Services

Document Types
  • Applications
  • Provider Forms
Plans
  • ALL

Provider Application 1-2 Bed AFH

Document Types
  • Applications
  • Provider Forms
Plans
  • iCare Family Care Partnership

Provider Application-Behavioral Health Services

Document Types
  • Applications
  • Behavioral Health
  • Policies and Guidelines
  • Provider Forms
Plans
  • ALL

Provider Applications List

Document Types
  • Applications

Provider Bulletin Issue 4 2024

Document Types
  • Claims
  • Internal Guidance for Providers
Plans
  • ALL

Provider Employee Roster 1pg

Document Types
  • Applications

Provider Resource_11.2024

Document Types
  • Formulary/ Pharmacy Documents
  • Internal Guidance for Providers
  • Plan Information
Plans
  • ALL

Rate increase-2021 State Rate Increase Communication_10.21.pdf

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

Rate increase-20211116HCBSARPA 5 Percent Increase Summary Final.pdf

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

Rate increase-DHS 2021 State Directed Rate Increase_Notice to Providers.pdf

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

Rate increase-iCare FCP HCBS inclusion logic.pdf

Document Types
  • Policies and Guidelines
Plans
  • iCare Family Care Partnership

Reconsideration-Formal Appeal Form

Document Types
  • Claims
  • Policies and Guidelines
  • Provider Forms

Remittance Advice Guide

Document Types
  • Claims
  • Policies and Guidelines

Review & Reopening Form - updated 2/2024

Document Types
  • Claims
  • Provider Forms

SNF Claim Processing Guidelines

Document Types
  • Claims
  • Policies and Guidelines

Subacute PA Form 2024

Document Types
  • Internal Guidance for Providers
  • Prior Authorization
Plans
  • ALL
  • iCare BadgerCare Plus
  • iCare Family Care Partnership
  • iCare Medicaid SSI
  • iCare Medicare Plan

Taxonomy Code Requirements

Document Types
  • Claims
  • Policies and Guidelines

Therapy Services Claims

Document Types
  • Claims

Translation Instructions for Providers & Agencies

Document Types
  • Policies and Guidelines
Plans
  • ALL
  • iCare Family Care Partnership

Vision Claims

Document Types
  • Claims

Waiver of Liability Statement

Document Types
  • Policies and Guidelines
  • Provider Forms

WI.PA-0574-Molecular Testing for HLA- B*27 for Ankylosing Spondylitis

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1000-Inpatient Hospital Services

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1001-Ablation Techniques and Extracorporeal Shock Wave Therapy for Musculoskeletal Indications and Soft Tissue Wounds

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1002-Achalasia And Gastroesophageal Reflux Disease Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1007-Airway Clearance Devices

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1010-Allograft Transplantation of the Knee

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1011 - Ambulatory Cardiac Monitoring Devices

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1013-Artificial Intervertebral Disc Replacement

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1014-Athletic Pubalgia Surgery

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1016-Autism Spectrum Disorders Diagnosis and Treatment

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1017-Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1019-Balloon Dilation (Eustachian Tube and Sinus), Functional Endoscopic Sinus Surgery and RhinAer

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1020 - Bariatric Surgery

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1021-Benign Prostatic Hyperplasia Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1024-Blepharoplasty Blepharoptosis Repair and Brow Lift

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1026-Bone Graft Substitutes

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1028-Brachytherapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1029-Breast Imaging

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1030-Breast Reconstruction

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1031-Bronchial Thermoplasty

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1032 - Foot Surgical Procedures

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1033-Capsule Endoscopy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1034 - Cardiac Catheterization

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1035-Cardiac Electrophysiological Studies and Cardiac Catheter Ablation

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1037-Cardiac Single- Photon Emission Computed Tomography

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1039-Cardioverter Defibrillators/Cardiac Resynchronization Therapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1040-Carotid Revascularization

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1041-Carpal Tunnel Syndrome Surgical Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1045-Implantable Cardiac Devices for Hemodynamic Management

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1048-Code Compendium (Musculoskeletal and Neurologic)

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1051-Code Compendium (Wound Care)

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1053-Cold and Heat Therapy Devices

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1054-Colorectal Cancer Screening and Surveillance

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1056-Complementary and Alternative Medicine

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1057-Comprehensive Genomic Profiling and Genetic Testing for Solid Tumors

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1062-Coronary CT Angiography Fractional Flow Reserve with CT, Calcium Scoring

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1063-Percutaneous Coronary Intervention

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1064-Cosmetic and Reconstructive Surgery

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1065-Cryoablation

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1066-Deep Brain Stimulation and Cortical Stimulation

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1067-Diagnostic Esophagogastroduodenoscopy or Esophagoscopy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1070-Drug Testing

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1072-Dynamic Spinal Stabilization Devices

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1073-Elective Aorta and Iliac Artery Aneurysm Repair

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1074-Electric Tumor Treatment Fields

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1076 - Electrical Stimulators - Diaphragmatic Phrenic Nerve Functional and Neuromuscular

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1078-Electrothermal Intradiscal Therapies

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1080-Endobronchial Valves for Emphysema

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1081-Erectile Dysfunction and Peyronie's Disease Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1084-Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1085-Fecal Incontinence Evaluation and Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1087-Fusion Imaging for Cancer Indications

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1088-Fusion Imaging for Noncancer Indications

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1089 - Gastric Pacing - Gastric Electrical Stimulation

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
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WI.PA-1091-Gender Affirmation Surgery

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1092-Gene Expression Profiling for Cancer Indications

Document Types
  • Policies and Guidelines
  • Prior Authorization
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  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1095-Genetic and Biomarker Testing for Alzheimer Disease

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1096-Genetic and Coagulation Testing for Noncancer Blood Disorders

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1097 - Genetic Testing

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1100-Genetic Testing for Hereditary Breast Ovarian Pancreatic and Prostate Cancer

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1101-Genetic Testing for Hereditary Cancer

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1102-Genetic Testing for Cardiac Conditions

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1106-Genetic Testing for Hereditary Colorectal and Uterine Cancer

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1109-Genetic Testing for Diagnosis of Inherited Conditions

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1112-Genetic Testing for Hereditary Ataxias

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1119-Glaucoma Surgical Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1122-Headache and Occipital Neuralgia Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1123-Hip Arthroplasty

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1124-Hip, Knee and Shoulder Arthroscopic Surgeries

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1128-Hyperbaric Oxygen Therapy, Topical Oxygen Therapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1130-Hyperthermia for Treatment of Cancer

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1132-Implantable and Non-Implantable Hearing Devices

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1133-Implantable Infusion Pumps for Pain or Spasticity

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1135-Infertility Evaluation and Treatment

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1137-Injections for Chronic Pain Conditions

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1138-Intensity Modulated Radiation Therapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1139 - Interspinous Process Decompression Spacers

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1140-Peripheral Nerve Stimulators

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1141-Intraoperative Neurological Monitoring

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1145-Knee Arthroplasty

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1146-Molecular Biomarkers for Prostate Cancer Risk Stratification

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1147-Laparoscopic Hiatal Hernia Repair

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1150-Left Atrial Appendage Closure and Cardiac Structural Defect Closure for Stroke Prevention

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1151 - Liquid Biopsy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1152-Low Level Laser Therapy and High Power Laser Therapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1154-Lymphedema - Diagnosis and Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1156-Microwave Thermotherapy

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1158-Molecular Diagnostic Assays and Breath Testing for Transplant Rejection

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1161-Molecular Markers in Fine Needle Aspirates of Thyroid Nodules

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1163-Multianalyte Assays with Algorithmic Analyses for Cancer Indications

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1165-Multiplex Pathogen Identification Panels for Infectious Disease

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1166-Negative Pressure Wound Therapy

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1168-Neuroablative Techniques for Chronic Pain

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1169-Noninvasive Home Ventilators

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1171-Noninvasive Tests for Hepatic Fibrosis

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1172-Obstructive Sleep Apnea and Other Related Sleep Disorders Nonsurgical Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1173-Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1174-Ocular Surface Disease Diagnosis and Treatments

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1175-Omisirge (omidubicel-onlv)

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1176-Orthognathic Surgery

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1177-Orthotics

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1178-Osteochondral and Subchondral Defects Surgery

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1180-Percutaneous Vertebroplasty, Kyphoplasty (Balloon-Assisted Vertebroplasty), Sacroplasty

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1182 - Peripheral Artery Revascularization of the Lower Extremities

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1185-Pharmacogenomics and Companion Diagnostics

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1186-Outpatient Rehabilitation (Physical Therapy, Occupational Therapy)

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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1188-Platelet Derived Growth Factors for Wound Healing

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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1193-Prostatectomy

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1194-Prosthetics

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1195-Proton Beam Neutron Beam and Carbon Ion Radiation Therapy

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1198-Radiofrequency Tumor Ablation

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1200-Reduction Mammaplasty

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1201-Rheumatoid Arthritis: Biologic Markers and Pharmacologic Assessment

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1204-Serological and Fecal Testing for Inflammatory Bowel Disease

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1207-Shoulder Arthroplasty

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1208-Skin and Tissue Substitutes

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1210-Skysona (elivaldogene autotemcel)

Document Types
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  • iCare Family Care Partnership
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WI.PA-1212-Solid Organ Transplants

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
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WI.PA-1215-Spinal Cord Stimulators

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
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WI.PA-1216-Spinal Decompression Surgery

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1217-Spinal Fusion Surgery

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1218-Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1220-Temporomandibular Disorders

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1221 - Thyroid Surgeries (Thyroidectomy_Lobectomy)

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1223-Tinnitus Treatments

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1225-Transcatheter Peripheral Vascular Stents-Chest, Abdomen and Pelvis

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1226-Transcatheter Valve Procedures

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1227-Cranial Electrical Stimulation

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1229-Ultraviolet Light/Laser Therapy for Skin Conditions

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1230-Urinary Bladder Dysfunction

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1231-Uterine Fibroid Surgical Treatments

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1232-Vagus Nerve Stimulation

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1233-Varicose Vein Treatments

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1234-Ventricular Assist Device, Total Artificial Heart

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1235-Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1239-Zynteglo (betibeglogene autotemcel)

Document Types
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Plans
  • iCare Family Care Partnership
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WI.PA-1240-Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1241-Measurable (Minimal) Residual Disease Testing

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1248-Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1248-Gene Expression Profiling for Noncancer Indications

Document Types
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Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1249-Hospital Services (Long Term Care Hospitals (LTCH), Observation)

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1250 - Cardiac Pacemakers

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1251-Transesophageal and Transthoracic Echocardiogram

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1252-Diagnostic Imaging

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1254-Excision and Mastectomy for Breast Lesions

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1255-Facility Based Sleep Studies

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1256-Lung Biopsy and Resection

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1259-Early Prostate Cancer Detection

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1260-Special Stains

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1266 - Irreversible Electroporation

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-1267 - Tecelra (afamitresgene autoleucel)

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-9000-Psychiatric Inpatient Hospitalization

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-9001-Psychiatric Partial Hospital Program Services

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-9002-Substance Use Disorder Inpatient Services

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-9003-Substance Use Disorder Partial Hospital Program Services

Document Types
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  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

WI.PA-CAR-T-Pharmacy Policy-Tecartusbrexucabtagene autoleucel-

Document Types
  • Policies and Guidelines
  • Prior Authorization
Plans
  • iCare Family Care Partnership
  • iCare Medicare Plan

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