Provider Documents

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Provider Documents that match your criteria:

1.7.22_2022-03 ARPA Rate Increase for Select Home and Community-Based Services.pdf

Document Types

Policies and Guidelines

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

2024 Comprehensive Formulary - updated 11/1/2024

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 11/1/24

Document Types

Formulary/ Pharmacy Documents

Plans

iCare Family Care Partnership
iCare Medicare Plan

2024 Step Therapy Prescription Drug Criteria - updated 11/1/2024

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

Advance Directives - Power of Attorney, Living Will brochure

Plans

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

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Policies and Guidelines

ARPA Procedure Code list 01 09 2022.pdf

Document Types

Policies and Guidelines

AVOID PAYMENT DELAY_Residential LTC Claim Tips

Document Types

Claims

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

Borrower Paycheck Protection Program Application

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Provider News/Bulletin

Chiropractor Claims Processing Guidelines

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Claims

Civil Rights Compliance Plan Form

Document Types

Applications

Claim Form - LTC Professional - updated 1/2024

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Claims
Provider Forms

Plans

iCare Family Care Partnership

Claim Form - LTC Residential - updated 11/2024

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Claims

Plans

iCare Family Care Partnership

Clean Claim Requirements (CMS 1500)

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Claims

Plans

Clean Claim Requirements (UB-04)

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Claims

Plans

COVID 19 Claims & Coverage Guide

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Claims
Prior Authorization

Cultural Competency Training 1

Document Types

Provider News/Bulletin

Cultural Competency Training 2

Document Types

Health Education
Policies and Guidelines

Current iCare Prior Authorization List (PAL) - excel

Document Types

Prior Authorization

Current iCare Prior Authorization List (PAL) - pdf

Document Types

Prior Authorization

Demographic Change Form

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Provider Forms

Diagnosis Specificity

Durable Medical Equipment/Supplies (DME/DMS) Claims

Document Types

Claims

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

Electronic Visit Verification Live-In Worker ID form

Document Types

Provider Forms

Enhanced Ambulatory Patient Grouping Announcement

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Policies and Guidelines
Provider News/Bulletin

F02717-EVV-Live-In Worker ID fillable form

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Prior Authorization
Provider Forms

FCP Provider Reference Manual

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Internal Guidance for Providers
Policies and Guidelines
Provider Forms

Plans

iCare Family Care Partnership

FDR Attestation Form

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Policies and Guidelines
Provider Forms

Plans

Fraud Waste and Abuse Training

Document Types

Policies and Guidelines

General Compliance Training/Combating Medicare Fraud Waste & Abuse

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Policies and Guidelines

General Subacute Communication to Providers

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Policies and Guidelines
Prior Authorization

Plans

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

How to Submit a Professional LTC Claim

Document Types

Claims

How to Submit a Residential Claim

Document Types

Claims

How To_LTC Professional Claim submission via iCare Provider Portal with screenshot

Document Types

Claims

How To_LTC Professional Claim submission via SSI Claimsnet

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Claims

How To_LTC Residential Claim Submission via iCare Provider Portal with screenshot

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Claims

HPMS Memo NPPES Provider Directory 1-3-2020

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Policies and Guidelines

Plans

iCare Coverage Criteria FAQ Document

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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

iCare Provider Portal Registration Guide

Document Types

Policies and Guidelines

iCare Provider Portal User Guide

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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

iCare Residential Availability Form

Document Types

Provider Forms

Plans

iCare Family Care Partnership

iCare Urine Drug Screen Guidance for Providers

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Policies and Guidelines
Prior Authorization

Plans

iCare Urine Drug Screen Policy

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Internal Guidance for Providers
Policies and Guidelines
Prior Authorization

Plans

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

InstaMed Order Form - Payer Payments

Document Types

Claims

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

Medicare FCP and SNP Appeal Language 3.1.2023

Medicare Star Ratings

Document Types

Policies and Guidelines

Plans

iCare Family Care Partnership
iCare Medicare Plan

Medication Reconciliation Post-Discharge Form

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Formulary/ Pharmacy Documents
Provider Forms

Plans

Medication Request Form

Document Types

Formulary/ Pharmacy Documents
Prior Authorization
Provider Forms

Plans

Member Handbook Changes Summary Template Draft for MCOs

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Grievances & Appeals
Policies and Guidelines

Plans

iCare Family Care Partnership

Mental/Behavioral Health & AODA Claims Guide

Document Types

Claims

New Provider Education - updated 09.2024

Document Types

Claims
Internal Guidance for Providers
Policies and Guidelines
Provider News/Bulletin

Plans

Non-Discrimination Notice

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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

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

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

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Policies and Guidelines
Prior Authorization
Provider Forms

Plans

iCare Family Care Partnership

Personal Care Screening Tool - MS Word Format

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Applications
Prior Authorization
Provider Forms

Plans

iCare Family Care Partnership

Personal Care Screening Tool (Form)

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Policies and Guidelines
Prior Authorization
Provider Forms

Plans

iCare Family Care Partnership

Personal Care Worker (PCW) Claims

Document Types

Claims

Policy - Caregiver Background Check

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Policies and Guidelines

Plans

iCare Family Care Partnership

Policy - Clinical Practice Guidelines

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Health Education
Internal Guidance for Providers
Policies and Guidelines

Plans

Policy - CO-013 Fraud Waste and Abuse Prevention and Detection Policy

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Policies and Guidelines

PPP Borrower Information Fact Sheet

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Provider News/Bulletin

Practitioner Attestation

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Applications
Policies and Guidelines
Provider Forms

Prescriber Enrollment Update Notice from CMS

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Formulary/ Pharmacy Documents
Policies and Guidelines
Provider News/Bulletin

Prior Authorization Requirements - In Home Meals

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Policies and Guidelines
Prior Authorization

Procedure Specific Listing Q1-2023.pdf

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Prior Authorization

Procedure Specific Listing Q1-2023.xlsx

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Prior Authorization

Provider Application - Durable Medical Equipment

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Applications
Claims
Provider Forms

Plans

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

Provider Application 1-2 Bed AFH

Document Types

Applications
Provider Forms

Plans

iCare Family Care Partnership

Provider Application-Behavioral Health Services

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Applications
Behavioral Health
Policies and Guidelines
Provider Forms

Plans

Provider Applications List

Document Types

Applications

Provider Bulletin Issue 4 2024

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Claims
Internal Guidance for Providers

Plans

Provider Employee Roster 1pg

Document Types

Applications

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

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Policies and Guidelines

Plans

iCare Family Care Partnership

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

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Policies and Guidelines

Plans

iCare Family Care Partnership

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

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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

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Claims
Policies and Guidelines

Review & Reopening Form - updated 2/2024

Document Types

Claims
Provider Forms

SNF Claim Processing Guidelines

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

Document Types

Policies and Guidelines
Prior Authorization

Plans

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
iCare Medicare Plan

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

Plans

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

Policies and Guidelines
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

Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1102-Genetic Testing for Cardiac Conditions

Document Types

Policies and Guidelines
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

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1130-Hyperthermia for Treatment of Cancer

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1135-Infertility Evaluation and Treatment

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1137-Injections for Chronic Pain Conditions

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1138-Intensity Modulated Radiation Therapy

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1139 - Interspinous Process Decompression Spacers

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1140-Peripheral Nerve Stimulators

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1141-Intraoperative Neurological Monitoring

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1145-Knee Arthroplasty

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1147-Laparoscopic Hiatal Hernia Repair

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1151 - Liquid Biopsy

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1154-Lymphedema - Diagnosis and Treatments

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1156-Microwave Thermotherapy

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1166-Negative Pressure Wound Therapy

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1168-Neuroablative Techniques for Chronic Pain

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1169-Noninvasive Home Ventilators

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1171-Noninvasive Tests for Hepatic Fibrosis

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iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1176-Orthognathic Surgery

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1177-Orthotics

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1178-Osteochondral and Subchondral Defects Surgery

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1185-Pharmacogenomics and Companion Diagnostics

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1193-Prostatectomy

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1194-Prosthetics

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1198-Radiofrequency Tumor Ablation

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1200-Reduction Mammaplasty

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1201-Rheumatoid Arthritis: Biologic Markers and Pharmacologic Assessment

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iCare Family Care Partnership
iCare Medicare Plan

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

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1207-Shoulder Arthroplasty

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1208-Skin and Tissue Substitutes

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1210-Skysona (elivaldogene autotemcel)

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1212-Solid Organ Transplants

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1215-Spinal Cord Stimulators

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1216-Spinal Decompression Surgery

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1217-Spinal Fusion Surgery

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1218-Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

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Policies and Guidelines
Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1220-Temporomandibular Disorders

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1221 - Thyroid Surgeries (Thyroidectomy_Lobectomy)

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1223-Tinnitus Treatments

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1225-Transcatheter Peripheral Vascular Stents-Chest, Abdomen and Pelvis

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1226-Transcatheter Valve Procedures

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1227-Cranial Electrical Stimulation

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1229-Ultraviolet Light/Laser Therapy for Skin Conditions

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Prior Authorization

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iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1230-Urinary Bladder Dysfunction

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1231-Uterine Fibroid Surgical Treatments

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1232-Vagus Nerve Stimulation

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1233-Varicose Vein Treatments

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1234-Ventricular Assist Device, Total Artificial Heart

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1235-Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1239-Zynteglo (betibeglogene autotemcel)

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1240-Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

Document Types

Policies and Guidelines
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

Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1255-Facility Based Sleep Studies

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1256-Lung Biopsy and Resection

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1259-Early Prostate Cancer Detection

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1260-Special Stains

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1266 - Irreversible Electroporation

Document Types

Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-1267 - Tecelra (afamitresgene autoleucel)

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-9000-Psychiatric Inpatient Hospitalization

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-9001-Psychiatric Partial Hospital Program Services

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

WI.PA-9002-Substance Use Disorder Inpatient Services

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Policies and Guidelines
Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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

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Prior Authorization

Plans

iCare Family Care Partnership
iCare Medicare Plan

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