Providers
Family Care Partnership
The Family Care Partnership (FCP) Program is an integrated health and long term care program for frail elderly and people with disabilities. The Independent Care Health Plan Partnership Program serves eligible individuals in Milwaukee County. The goals of Partnership are to:
- Improve quality of health care and service delivery while containing costs;
- Reduce fragmentation and inefficiency in the existing health care delivery system; and
- Increase the ability of people to live in the community and participate in decisions regarding their own health care and personal health goals.
Interdisciplinary Team
An Interdisciplinary Team (IDT), composed of the FCP member and, at a minimum, an iCare Care Manager, a Registered Nurse, and a Nurse Practitioner is assigned upon enrollment into the iCare Family Care Partnership Program. As appropriate, a guardian, caretakers, and/or other professionals may also participate as members of the Team. The IDT conducts a comprehensive assessment of members’ needs, abilities, preferences, and values to develop a Member Centered Plan (MCP). The IDT will utilize the Resource Allocation Decision-Making (RAD) process developed by the State of Wisconsin to determine cost-effective strategies to make use of available resources and services to meet a particular outcome. The Nurse Practitioner will request a collaboration agreement with the member’s physician to facilitate communication and care coordination.
Provider Network
FCP Provider Reference ManualIn order to assure access to services, Independent Care Health Plan has developed a comprehensive network of long-term care service providers. All interested providers will be considered for iCare network participation and a contractual relationship. Contracted participation in the iCare network does not include a guarantee of utilization or exclusivity. Interested providers are requested to complete and return this form and other required documents by mail:
iCare
1555 RiverCenter Drive Suite 206
Milwaukee, WI 53212
fax: 414-231-1092
or email: (netdev@icare-wi.org).
Partnership Provider Application
Authorization and Provision of Services
All services must be authorized through the IDT. Prior to delivery of any services to an iCare FCP member, the provider must obtain a Service Authorization from the IDT staff at iCare outlining the specific services and rates of reimbursement. A written Service Authorization for each service to be provided will be sent to the provider.
The following information is required to consider a Service Authorization request:
- member name and number
- description of services to be provided (service must match service description and codes in provider agreement)
- units and frequency of service
- dates of service
- service location
Providers are requested to notify the IDT as soon as possible in an emergency situation. The IDT will work to authorize necessary services. For emergencies after-hours, please contact iCare at 414-223-4847 to reach the Care Manager on call.
Claims Submission
More InformationAll services for payment must match Service Authorization and be submitted on a claim form. Invoices are NOT acceptable for payment. Send completed claim form to:
BEGINNING DECEMBER1, 2011
Independent Care Health Plan
P.O. Box 904
Buckeystown, MD 21717
2012 iCare LTC Residential Services Claim Form
2012 iCare LTC Professional Services Claim Form
Drug Coverage Information
More InformationA list of our covered drugs, as well as descriptions of the additional requirements or limits on the coverage can be found within the Comprehensive Formularies below. Details regarding prior authorization requirements or step therapy criteria are also posted on this page.
2011 iCare Partnership Comprehensive Formulary
2012 iCare Partnership Comprehensive Formulary
Formulary Change Notice (iCare Partnership)
Requesting 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. Request an exception 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.
Medicare Part D Coverage Determination Form
Medicare Part D Coverage Redetermination Form
Medication Request Form - Partnership Medicaid
2011 Prior Authorization Criteria iCare Partnership
2012 Prior Authorization Criteria iCare Partnership
2011 Step Therapy Criteria iCare Partnership
2012 Step Therapy Criteria iCare Partnership
Notification:
By clicking the links above, you may be leaving the icare-wi.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 iCare.wi.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.
Provider Resources
PDF Resources
Listing of CMS approved iCare Medicare publications, Medicaid publications, third-party preventive health brochures.
- Abridged Formulary/iCare Medicare Plan 2012
- Abridged Formulary/iCare Partnership 2012
- Annual Notice of Change (ANOC)/iCare Medicare Plan 2012
- Annual Notice of Change (ANOC)/iCare Partnership 2012
- Anti-Smoking Quit Line (English)
- Anti-Smoking Quit Line (Spanish)
- Caregiver Background Check Policy
- Claim Form LTC Professional Services - Trizetto
- Claim Form LTC Residential Services - Trizetto
- CMS Appointment of Representative Form
- Comprehensive Formulary/iCare Medicare Plan 2012
- Comprehensive Formulary/iCare Partnership 2012
- Emergency Room Brochure
- Enrollment Form/iCare Medicare Plan 2012
- Evidence of Coverage/iCare Medicare Plan 2012
- Evidence of Coverage/iCare Partnership 2012
- Family Care Partnership Provider Application
- FCP Provider Reference Manual
- First Tier, Downstream and Related Entities Fraud
- Formulary Change Notice (iCare Medicare Plan)
- Formulary Change Notice (iCare Partnership)
- HCFA Claim Required Fields
- Limited English Proficiency Policy/Procedures
- LIS Premium Summary Sheet 2012
- Member Handbook/BadgerCare Plus Core Plan
- Member Handbook/iCare Medicaid SSI
- Member Recertification Reminder/BadgerCare Plus Core
- Notice of Privacy Practices
- Part D Coverage Determination Request Form
- Part D Prior Authorization Criteria/iCare Medicare Plan 2012
- Part D Prior Authorization Criteria/iCare Partnership 2012
- Part D Redetermination Request Form
- Pharmacy Listing/iCare Medicare Plan 2012
- Pharmacy Listing/iCare Partnership 2012
- Plan Comparisons/iCare Partnership 2012
- Power of Attorney brochure
- Primary & Acute Care Information Form
- Prior Authorization List 4/19/12
- Prior Authorization List 4/19/12 pdf
- Program Brochure/Hmong/iCare Medicaid SSI
- Program Brochure/iCare BadgerCare Plus
- Program Brochure/iCare Medicaid SSI
- Program Brochure/iCare Partnership
- Program Brochure/Spanish/iCare Medicaid SSI
- Program Overview (Spanish)/iCare Medicaid SSI
- Program Overview (Spanish)/iCare Partnership
- Provider Directory/iCare Medicaid SSI-BadgerCare Plus_Expansion Counties
- Provider Directory/iCare Medicaid SSI-BadgerCare Plus_Original Counties
- Provider Directory/Pharmacy Directory/iCare Medicare Plan Expansion Counties 2012
- Provider Directory/Pharmacy Directory/iCare Medicare Plan Original Counties 2012
- Provider Information Form (other than Partnership Program)
- Provider Reference Manual 2012
- Provider/Pharmacy Directory - iCare Partnership 2012
- Recertification Reminder (flyer)/BadgerCare Plus
- Self-Directed Supports Program Overview/iCare Partnership
- Step Therapy Prescription Drug Criteria/iCare Medicare Plan 2012
- Step Therapy Prescription Drug Criteria/iCare Partnership 2012
- Summary of Benefits/iCare Medicare Plan 2012
- Summary of Benefits/iCare Partnership 2012
- Transition Process
- UB Claim Required Fields
- Value to the Family
Call 1-800-777-4376 (TTY: 1-800-947-3529), from 8:00 a.m to 8:00 p.m.,
7 days-a-week, for further information about iCare.
