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Prior Authorization

 

PA Forms Services Requirements

PA Documents

 

In an increasingly complex health care environment, iCare is committed to offering solutions that help health care professionals save time and serve their patients. The prior authorization process is in place to assure iCare members receive the appropriate level of care and to mitigate potential fraud, waste, and abuse.

iCare Prior Authorization

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Updates from iCare’s Prior Authorization Department

Please note: Starting 04/01/2024, the PA Department will no longer be reviewing Medicaid Authorization requests that are received more than 14 days after admission.  The PA Department will respond to the request with our Retro Authorization Administrative Denial.

 

Prior Authorization Forms


The PA department has changed the Prior Authorization Request Form for DME, DMS, and Outpatient Procedures to include some critical information that will assist in the proper and accurate entry of an authorization request.

We hope these changes will make the form easier to use and will lead to better completion with less phone calls to determine incorrect or missing information.  Use the forms here to submit a prior authorization request. 

Outpatient PA Form   Inpatient PA Form   Subacute PA Form    

 

Prior Authorization List (PAL)


Current PAL (pdf)      Current PAL (excel)

The PDF can be searched using the F5 option and the excel version of this document can be filtered by category, code, or description.

To prevent disruption of care, iCare does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to the enrollment. iCare may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment.

 

The Prior Authorization Department has added new codes:

*Effective 3/01/25, the following codes will be added to the list requiring PA:

Procedures: 22836, 22837, 22838, 27278

Neurostimulators: 61889, 61891, 61892, 64596, 64597, 64598

Laboratory/Pathology:

81457, 81458, 81459, 81462, 81463, 81464, 0439U, 0440U, 0444U, 0448U, 0449U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0489U, 0493U, 0496U, 0497U, 0498U, 0499U, 0500U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U

DME/DMS:

A4593, A4594, E0468, E0469, E0492, E0493, E0678, E0679, E0680, E0681, E0682, E0683, E0721, E0732, E0733, E0734, E0735, E0736, E0738, E0739, E0743, E2298, E3000, K1037, L1320, L5615, L5783, L5841, L5926, L8720, L8721

Dressings/Skin Substitutes:

A2027, A2028, A2029, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345

Specialty Medications:

J2350    Ocrevus® (ocrelizumab) & Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq)

J1458    Naglazyme® (galsulfase)

J2323    Tysabri® (natalizumab)

J1930    Lanreotide Products

J2357    Xolair® (omalizumab)

J1300    Soliris® (eculizumab)

 

Medically Tailored Meals: S5170, S9977

Intensive Outpatient Services: H2019

Effective 3/1/2025, we are removing prior authorization requirements for:

V2623, V2624, V2625, V2626

Effective 4/1/2025, we will also require prior authorization for the following codes:

Procedures: 51721, 55881, 55882

Neurostimulators: 0908T, 0909T, 0910T, 0911T, 0912T, 0935T

DME/DMS/Supplies: C9804, C9806

CAR-T: 38225, 38226, 38227, 38228

 

These forms and other provider documents can be found under Provider Documents.

Please reach out to the Prior Authorization Department with questions by calling 1-855-839-1032 or emailing paassistants@icarehealthplan.org.

Personal Care Workers & PC Screening Tool

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

 

Personal Care Worker fillable form                  Personal Care Screening Tool              PC Screening Tool Instructions

 

These documents and others can also be found on the Prior Authorizations Documents page.

 

Services and Procedures Requiring Prior Authorization/Utilization Management Review

Prior authorization is required for:

  • Behavioral Health or Medical Admissions to an Inpatient Hospital
  • Admission to a subacute facility (Skilled Nursing Facility, Long Term Acute Care Hospital, Inpatient Rehabilitation Facility)
  • Home health care services
  • Hospice
  • Select durable medical equipment
  • Select procedures
  • Outpatient physical, occupational, and speech therapy & cardiac and pulmonary rehabilitation
  • Transplants
  • Referrals
    • For second (or addition) opinions
    • Referrals to non-participating providers outside of the member’s home state
  • For Non-Medicaid certified Providers –All Services other than Emergency Services
  • All Category III procedure codes
  • Long term care services covered under iCare’s Family Care Partnership Program also require a service authorization request from the Interdisciplinary Team.

Please note that supporting clinical documentation is required for all prior authorization requests in order to determine medical necessity. Incomplete prior authorization requests may delay processing. iCare will not retro authorize services rendered prior to the submission of a prior authorization request.

For information about Pharmacy Part D prior authorizations, coverage determinations or formulary exceptions, visit the Drug Coverage Information for Providers page.

For authorization requirements, visit the Authorization Requirements page. 

 

Should you need to file a formal complaint:    Submit a CMS complaint form online 

 

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Last Updated 2/20/24

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