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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, please refer to Humana's Medical and Pharmacy Coverage Policies; iCare is a subsidiary of Humana, and coverage policies are located on Humana's Medical and Pharmacy Coverage Policies page. Enter the number or name of the policy referenced in your letter in the keyword search box on this page.

iCare Health Plan also utilizes Care Guidelines to determine medical necessity for the plans that we manage. The Guidelines are the protected intellectual property of MCG. iCare Health Plan is not able to distribute them without the permission of MCG. MCG has provided a tool that allows iCare Health Plan members and prospective members to view relevant MCG guidelines, however you will not be able to print them.

Follow the instructions below to access the MCG Guidelines:

  1. Access guidelines here, read the disclaimer, and accept the terms and conditions.
  2. Complete the User information form.
  3. Complete the verification process to continue.
  4. Click on the arrow icon.
  5. Click on the guidelines you wish to view.

iCare has prepared some FAQs​​​​​​​ for Medicare Advantage coverage policies.

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More Prior Authorization Documents

Inpatient Prior Authorization Request Form

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

iCare Prior Authorization Request Form

Providers use this updated form to request a prior authorization

Current iCare Prior Authorization List (PAL) - pdf

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.

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.

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

Subacute PA Form 2024

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 - 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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