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Prior Authorization (PA)
Inpatient Notification
Procedure: All elective inpatient admissions must be called into
iCare
within five business days prior to admission by the physician's office.
This allows iCare to initiate early discharge planning. Hospitals must
ALWAYS notify iCare of all inpatient admissions, elective or emergent,
by
the following business day.
Prior Authorization
Phone: 414-231-1096
Fax: 414-231-1026
Prior Authorization Forms
Guidelines
for OxyCodone Use
Services Requiring Prior Authorization
All requests must be
submitted by the physician to iCare no less than five business days
(or as soon as possible) prior to
the procedure.
- Any
inpatient admission with a pre-op day or one-day length of stay
- Home
Health (Requires a 485 form)
- DME >
$200.00 (Requires a DME form)
-
Therapy (PT, OT, Speech, Cardiac, Pulmonary)
-
Orthotics/Prosthetics
- Air
Transport
Inpatient/Outpatient Procedures Requiring Prior
Authorization
- Dermabrasion/Scar
abrasion or revision
- Chemical peel/keloids
- Transplant evaluation and
requests
- Varicose vein ligation
- Mastectomy for
Gynecomastia
- Augmentation/Reduction
Mammoplasty
- Removal breast implant
- LaForte procedures
- Tempromandibular Joint (TMJ)
- TMJ Arthoplasty
- Rhinophyma (Nasal
surgery)
- Rhinoplasty and/or
Septoplasty
- Uvulopalatopharyngoplasty
(UPPP)
- Gastric banding,
Gastrojejunostomy, Gastric Bypass
- Cosmetic eye procedures:
Brow ptosis, repair blepharoptosis, correction lid retraction
- Blepharoplasty
- Otoplasty
- Cochlear implant
- Pain management
procedures
- Nerve stimulators
Please note that services and authorizations
are subject to change. |
