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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.

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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Policies and Guidelines

WI.PA-1250 - Cardiac Pacemakers

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

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

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

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

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

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

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

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

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

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

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iCare Coverage Criteria FAQ Document

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

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WI.PA-1013-Artificial Intervertebral Disc Replacement

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

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WI.PA-1026-Bone Graft Substitutes

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WI.PA-1040-Carotid Revascularization

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WI.PA-1041-Carpal Tunnel Syndrome Surgical Treatments

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WI.PA-1056-Complementary and Alternative Medicine

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WI.PA-1074-Electric Tumor Treatment Fields

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WI.PA-1078-Electrothermal Intradiscal Therapies

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

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

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WI.PA-1138-Intensity Modulated Radiation Therapy

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WI.PA-1141-Intraoperative Neurological Monitoring

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WI.PA-1147-Laparoscopic Hiatal Hernia Repair

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

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WI.PA-1166-Negative Pressure Wound Therapy

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WI.PA-1169-Noninvasive Home Ventilators

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WI.PA-1185-Pharmacogenomics and Companion Diagnostics

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WI.PA-1210-Skysona (elivaldogene autotemcel)

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WI.PA-1212-Solid Organ Transplants

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WI.PA-1226-Transcatheter Valve Procedures

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WI.PA-1233-Varicose Vein Treatments

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WI.PA-1239-Zynteglo (betibeglogene autotemcel)

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

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WI.PA-1252-Diagnostic Imaging

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WI.PA-1256-Lung Biopsy and Resection

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WI.PA-9002-Substance Use Disorder Inpatient Services

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

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More Prior Authorization Documents

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.

Current iCare Prior Authorization List (PAL) - excel

Current iCare Prior Authorization List (PAL) - pdf

WI.PA.001-Outpatient Skilled Services, Home Health Services, Durable Medical Equipment, and Procedures PA Process

iCare Prior Auth Request Form

Providers use this updated form to request a prior authorization

Subacute PA Form 2024

Inpatient Notification Form

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

PA Request - Personal Care Worker (PCW) fillable form

Procedure Specific Listing Q1-2023.pdf

Procedure Specific Listing Q1-2023.xlsx

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

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.

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.

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.

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.

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 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.

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

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.

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