Prior Authorization

Prior Authorization

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.

Services and Procedures Requiring Prior Authorization

Prior authorization is required for:

  • 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 third opinions, and out of state providers
  • 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 prior authorization from the Interdisciplinary Team.
    • Please refer to the Family Care Partnership link under Provider Resources at www.icarehealthplan.org for more information.

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 determination of a prior authorization.

Please reference the links below for additional information.

For detailed procedure code specific information regarding services, procedures and devices that require prior authorization, please reference the Prior Authorization Procedure Specific Listing. Please note that this list is updated on a quarterly basis. Please check the date on the form to ensure you are referencing the most up to date version.

  • Prior Authorization Updates
    PRIOR AUTHORIZATION UPDATE
    16 October 2017

    As of 10/01/2017, iCare no longer requires prior authorization for neuropsychological exams, including all of the following codes, in accordance with the State of Wisconsin DHS authorization guidelines. For your reference, please review the BagerCare Plus and Medicaid Outpatient Mental Health coverage critieria (ForwardHealth topic #6057).

    LIST OF CODES: 96101-96103, 96105, 96110, 96111, 96116, 96118, 96119-96120, 96125



    PERSONAL CARE WORKER (PCW) PROVIDER UPDATE
    01 March 2017

    Effective July 1st, 2017 iCare will no longer require that new requests for PCW services be submitted with a copy of the PCST completed by the requesting provider. The requesting provider must fill out a PA request form leaving the following fields blank: units (with the exception of travel time) and dates of service). The initial request must also include a copy of the signed physicians order and MapQuest, Google Maps, etc. if travel time is being requested. Once iCare receives the request, a 3rd party assessment will be completed. The assessment will then be reviewed by a prior authorization nurse and services will be approved based on the findings of the 3rd party assessment. iCare will fax a copy of the approved authorization as well as the PCST completed by the 3rd party assessor to the requesting provider. All new PCW services will be authorize for 60 days from the date of assessment. iCare will not authorize any services rendered prior to the date of the 3rd party assessment.

    Ongoing Services: Ongoing services may continue to be requested in 60, 90 and 180 day increments. Ongoing services must be requested and will continue to require an updated signed physician’s order/plan of care. For ongoing services, all PA requests are required to be submitted within 7 days after the expiration date of the previous authorization. iCare will not retro authorize any services submitted after the 7th day.

    Increase in Services: If a provider believes a member qualifies for additional services they will still be able to make a request for an increase in services. All requests for increased services must include a signed physicians order and clinical documentation to support the increase. iCare will conduct 3rd party reassessments on a case by case basis. Short term increases will be authorized based on a member’s condition and for a maximum of 60 days.

    A blank/fillable copy of the PCST is available at http://www.icare-wi.org under the Prior Authorization section.



    PRIOR AUTHORIZATION UPDATE
    01 March 2017

    Effective April 1, 2017, iCare’s updated Procedure Specific Listing (Prior Authorization List) will replace the current version (dated 01/01/2017). All new codes requiring prior authorization are highlighted in yellow. Please note this list will be updated on a quarterly basis. Please check the dates on the form to ensure you are using the most recent version. All providers are required to submit prior authorization for review of medical necessity for all CPT and HCPCS codes listed. To view the updated list

    Click Here

    PRIOR AUTHORIZATION UPDATE
    02 February 2017

    As of 4/1/17, PA’s will no longer be required for Day Treatment, Intensive Outpatient Services, Partial Hospitalization and Crisis Stabilization. H2012 and H0018 have been removed from the prior authorization list.

    You will be able to bill for services you provided by submitting directly to our claims system. The Forward Health parameters and Medicare guidelines for behavioral health services have been built into the claims system. Please refer to the Forward Health Handbooks and Medicare guidelines for instruction.

    We will request that a notification of service be submitted instead, by faxing assessment, to include plan of care and at discharge, a discharge summary. Please fax these documents to: Fax Number: 414-231-1090, Attention: Behavioral Health Programing.



    PRIOR AUTHORIZATION UPDATE
    02 November 2016

    Effective January 1st 2017, iCare is updating their prior authorization process for all manual wheelchairs covered by Medicare to ensure that all iCare Medicare members meet approval criteria set forth by the Centers for Medicare and Medicaid Services (CMS). If the member meets all of the CMS criteria for approval, with the exception of documentation to support accessibility of the member’s home for wheelchair use, the prior authorization request will be pended, with final determination contingent upon the home assessment completed at the time of delivery. It is the supplier’s responsibility to submit documentation verifying that the member’s home provides adequate access between rooms, maneuvering space, and surfaces for the use of the manual wheelchair, by the date listed on the provider notification form. As outlined in CMS Local Coverage Determination L33788, issues such as the physical layout of the home, surfaces to traverse, and obstacles must be addressed and documented in the home assessment. Upon receipt of this documentation, iCare will approve the prior authorization request from the date the initial prior authorization request was submitted. If the documentation is not received, or the member’s home is not accessible for manual wheelchair use, the prior authorization request will be denied.



  • Prior Authorization Forms

    Upon receipt of all required information, urgent prior authorization requests are processed within 72 hours and fourteen (14) calendar days for standard requests. To request services which require prior authorization, please complete the appropriate form below and send completed form along with clinical documentation supporting medical necessity to the fax number listed on the form.

  • Inpatient Notification

    Notification of all inpatient admissions (medical and behavioral) must be faxed to iCare (414-231-1075), using the Inpatient Notification Request form, within one (1) business day of admission. This allows iCare to initiate discharge planning. Hospitals must ALWAYS notify iCare of all inpatient admissions whether they are elective or emergent.

  • Subacute Facilities Prior Authorization

    All sub-acute facility (skilled nursing facility, inpatient rehab facility, long term acute care hospital) admissions require prior authorization. All prior authorization requests and clinical documentation to support medical necessity must be faxed to iCare, using the Subacute Facilities Prior Authorization Request form, and approved prior to the member's admission to the facility. Prior authorization must be submitted at least 24 hours prior to the date of admission. iCare completes concurrent reviews on all subacute facility prior authorization requests.

  • Behavioral Health Prior Authorization
    • As of 4/1/17, prior authorization for behavioral health and AODA programming using codes H2012 and H0018 will no longer be required. Claims will mimic Forward Health guidelines regarding these codes. Please also refer to the procedure specific code listing and other prior authorization information on the iCare website to confirm prior authorization requirements. This page is located here:http://www.icarehealthplan.org/providers/authorization.aspx
    • Changes are: 1) Providers no longer submit the PA request form for codes H2012 and H0018; 2) Providers no longer call in reviews; 3) In lieu of the PA process, providers will fax the intake summary and discharge summary for any iCare member participating in programming to fax: 414-231-1090, Attention: Gatekeeping where the faxes will be distributed to Eleni Voulgaris and Megan Barcelona to be used to support iCare’s Care Management Model of Care – all iCare members have a care coordinator or care manager and nurse available to assist with their needs.
    • Please contact Eleni Voulgaris (Phone: 414-231-1065) and Megan Barcelona (Phone: 414-299-5468) if you have additional questions.
    • Psychological Testing (greater than 4 hours) requires prior authorization. Please use the forms below to request prior authorization:
    • For any questions regarding Behavioral Health Authorization, please call 1-855-893-0476.
  • Outpatient PT, OT, ST, And Cardiac & Pulmonary Rehabilitation Prior Authorization

    Prior Authorization is required for all outpatient therapy services including PT, OT, and SLP.

    iCare authorizes outpatient therapy by number of visits; however, the CPT codes that the provider anticipates billing MUST be listed on the prior authorization request form in order tocomplete the clinical review and determine medical necessity.

    Comprehensive information about the member helps to establish the functional potential of the member and forms the basis for determining whether the member will benefit from the requested services. Please submit the Prior Authorization Request form along with the completed therapy evaluation, plan of care, and signed physicians prescription for review to determine if the service is medically necessary.

    Outpatient therapy will be authorized based on medical necessity. Services that are medically necessary are defined under Wis. Admin. Code § DHS 101.03(96m). The provider is responsible to assure that the services provided are covered under the Medicare or Medicaid benefit, whichever applies.

    An approved PA request will be backdated to the initial date of the evaluation if the PA request is received within 14 calendar days of the initial therapy evaluation. iCare will not retro authorize any authorization requests submitted beyond the 14 calendar days of the initial evaluation.

    Continuing therapy requests may be requested when the member's need for therapy services is expected to exceed the maximum allowable treatment days authorized.

    For continuing therapy requests, prior authorization must be obtained. PA requests for ongoing therapy will not be backdated. To request additional visits, please submit the completed Prior Authorization Request form, as well as clinical documentation to support medical necessity for ongoing therapy services.

    PA requests are approved for varying periods of time based on the clinical justification submitted. The provider receives a copy of a PA decision notice when a PA request for a service is approved. Providers may then begin providing the approved service on the start date given.

    An approved request mean that the requested service, not necessarily by code, was approved. Providers are encouraged to review approved PA requests to confirm the services authorized and confirm the assigned start and end dates.

    All claims for services are subject to the coverage and medical necessity guidelines provided by Medicare and Medicaid.

    Medicare Guidelines for Outpatient Physical and Occupational Therapy Services can be found here.

    Medical Guidelines can be found here.

  • Home Health & Hospice Prior Authorization
    30 May 2017

    New Services:
    Effective July 1st, 2017 iCare will no longer require that new requests for PCW services be submitted with a copy of the PCST completed by the requesting provider. The requesting provider must fill out a PA request form leaving the following fields blank: units (with the exception of travel time) and dates of service). The initial request must also include a copy of the signed physicians order, history and physical/clinic notes from a medical doctor and MapQuest, Google Maps, etc. if travel time is being requested. Once iCare receives the request, a 3rd party assessment will be completed. The assessment will then be reviewed by a prior authorization nurse and services will be approved based on the findings of the 3rd party assessment. iCare will fax a copy of the approved authorization as well as the PCST completed by the 3rd party assessor to the requesting provider. All new PCW services will be authorize for 60 days from the date of assessment. iCare will not authorize any services rendered prior to the date of the 3rd party assessment.

    Ongoing Services:
    Ongoing services may continue to be requested in 60, 90 and 180 day increments. Ongoing services must be requested and will continue to require an updated signed physician’s order/plan of care. For ongoing services, all PA requests are required to be submitted within 7 days after the expiration date of the previous authorization. iCare will not retro authorize any services submitted after the 7th day.

    Increase in Services:
    If a provider believes a member qualifies for additional services they will still be able to make a request for an increase in services. All requests for increased services must include a signed physicians order and clinical documentation to support the increase. iCare will conduct 3rd party reassessments on a case by case basis. Short term increases will be authorized based on a member’s condition and for a maximum of 60 days.

    A blank/fillable copy of the PCST is available at www.icarehealthplan.org under the Prior Authorization section.

    • In order to ensure that iCare members are receiving the appropriate level of care, all personal care worker (PCW) prior authorization requests will not be determined until a new or updated independent assessment is completed.  iCare will not retro authorize any services rendered prior the date of the independent assessment.
    • All PA requests for home health and hospice services must include a signed physician order and plan of care as well as the initial in home evaluation for review.
    • All PA requests for home health and hospice services must be submitted to iCare within 14 calendar days from the start of care.  iCare will not retro authorize any services submitted after the 14th day.
    • For ongoing services, all PA requests are required to be submitted within 7 days after the expiration date of the previous authorization.  iCare will not retro authorize any services submitted after the 7th day.
    • All late PA requests for home health and hospice services will be reviewed for medical necessity starting from the date the request was received by iCare.
    • iCare prior authorizes home health and hospice services for the following timeframes:
      • Personal Care Worker-180 days or 26 weeks
      • Skilled Nursing-60 days or 9 weeks
      • PT/OT/SLP/MSW-60 days or 9 weeks
      • Hospice-60 days or 9 weeks
  • Durable Medical Equipment Prior Authorization
  • Urine Drug Screen Prior Authorization

    iCare requires prior authorization for Testing for Drugs of Abuse in order to be compliant with the State's Policy for covered and non-covered services, substance abuse/dependence and chronic opioid pain treatment. Medicare beneficiaries must follow Medicare coverage determination guidelines.


    All outpatient drugs of abuse testing, both presumptive and definitive, require a prior authorization request.

    The following supporting clinical documentation is required to make a determination:

    • Clinical documentation that fully supports the medical necessity for the service rendered. This documentation includes, but is not limited to relevant medical history, physical examination, risk assessment, and results of pertinent diagnostic procedures.
    • A signed and dated member-specific order for each drug test. This order must provide sufficient information to substantiate each testing panel component performed. Standing orders, custom profiles, and orders to conduct additional testing as needed are insufficient and cannot be used to verify medical necessity.
    • Rationale for ordering a definitive drug test for each drug class tested
    • If a direct-to-definitive drug test is ordered, documentation supporting the inadequacy of presumptive drug testing.

    If a prior authorization for a urine drug screen is approved, it will be authorized for a 2 week timeframe.
    Independent Care Health Plan will authorize testing for drugs of abuse within the following guidelines:

    Presumptive Drug Testing in Treatment for Substance Abuse or Dependence (Presumptive tests):
    • Members who have abstained for ≤ 90 consecutive days: up to 1 to 3 tests per week.
    • Members who have abstained for ≥ 90 consecutive days: up to 1 to 3 tests per month.

    Definitive Drug Testing in Treatment for Substance Abuse or Dependence:
    • Members who have abstained for ≤ 30 consecutive days: up to 1 test per week (determined by medical necessity and clinical practice guidelines).
    • Members who have abstained for between 30-90 consecutive days, inclusive: up to 1 to 3 tests per month (determined by medical necessity and clinical practice guidelines).
    • Members who have abstained for ≥ 91 consecutive days: up to 1 to 3 tests per 3 months (determined by medical necessity and clinical practice guidelines).

    Presumptive Drug Testing in Chronic Opioid Therapy(Providers are required to document the prescribing frequency and rationale for prescribing opioid therapy, as well as performing a standardized risk assessment. This data must be included in the prior authorization request for presumptive drug testing in chronic opioid therapy):

    iCare will only authorize one urine drug screen at a time when the indication is chronic opioid therapy. Prior authorization requests for multiple urine drug screens will not be accepted.


    • Members with low risk for abuse: up to 1 to 2 times per year (determined by medical necessity and clinical practice guidelines).
    • Members with moderate risk for abuse: up to 1 to 2 times per 6 months (determined by medical necessity and clinical practice guidelines).
    • Members with high risk for abuse: up to 1 to 3 times per 3 months (determined by medical necessity and clinical practice guidelines).
  • Pharmacy Prior Authorization Or A Formulary Exception

    As indicated within the formulary, a Prior Authorization is required on certain medications before they will be covered. Links to the Prior Authorization forms are located below.  We have also provided additional details regarding prior authorization requirements and step therapy criteria. When the medications on our formulary used to treat a specific condition are not appropriate for a patient, you may request coverage of a non-formulary medication.  This type of request is called a Formulary Exception.  An exception may also be requested to the Step Therapy criteria when first-line agents are not appropriate for your patient, or to the Quantity Limit restrictions when the allowed quantity is not enough to adequately treat your patient’s condition.  The Prior Authorization forms located below may be used for formulary exceptions as well.  Supporting medical information must be submitted with any exception request.  The requests should be faxed to our Pharmacy Benefits Manager, MedImpact, at 858-790-7100.
    Or, you may click here to submit a prior authorization through the web. You will be redirected to MedImpact's website.

  • Referrals

    Referrals are required for out of area providers, and all second (or additional) opinions. To request prior authorization for a referral, please submit the Prior Authorization Request form as well as clinical documentation to support medical necessity for the requested referral.

  • Enhanced Benefits
    In Home Meals

    Medicare members transitioning from an inpatient hospital or skilled nursing facility to home may be eligible for up to 28 days of meals (maximum 56 meals provided). For additional information including requirements, benefit limits, and order form, click here.

    Philips Lifeline©

    Medicare members who are at risk for falls maybe eligible for Philips Lifeline© personal emergency response system (PERS). For additional information including requirements, benefit limits, and order form, click here.

  • Previous Prior Authorization Procedure Specific Listing

Notification:
By clicking the links above, 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 icarehealthplan.org website. These external links are not the responsibility of, or under the control of iCare. Independent Care Health Plan disclaims responsibility for the content and privacy policies of the owners/sponsors of the outside websites.

Modified: 9/20/2017
 

 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
  • Customer Service: 1-800-777-4376
    • 24 hours-a-day, 7 days-a-week
    • (Office Hours: Monday-Friday, 8:30 a.m. to 5:00 p.m.)
  • TTY: 1-800-947-3529
  • Fax: 414-231-1092
  • All content and images unless otherwise indicated are
  • Copyright © 2017 Independent Care Health Plan