Providers

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.

Prior Authorization Quick Reference Guide

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.

• Fax: 414-231-1075
• Inpatient Admission Notification Form

Behavioral Health Authorization and Notification Procedure:

Inpatient Mental Health and Alcohol or other Drug Abuse (AODA) treatment services require prior authorization. Other behavioral health services that require prior authorization are partial hospitalization, intensive outpatient programs, psychological testing greater than 4 hours and in-home treatment. Please use the forms below to request authorization. Fax completed forms to 414-321-1075

• Outpatient Behavioral Services:
  • Behavioral Health Outpatient Notification of Services Form

• Inpatient Behavioral Admissions:
  • Behavioral Health Inpatient Authorization Request Form

• Partial Hospital, Intensive Outpatient, Community Day Treatment programs, Psychological Testing (>4hours) and Rapid Response Program:
  • Behavioral Health Services and Procedures Authorization Form
  • Questions regarding Behavioral Health Authorization:
    1-855-893-0476

Other Prior Authorization Forms:

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.  For services requiring prior authorization, please complete the appropriate form below and send completed form to:

Fax: 414-231-1026
Mail: Independent Care Health Plan
1555 RiverCenter Dr. Suite 206
Milwaukee, WI 53212

• General Prior Authorization form
• Home Health/Personal Care Worker
• Therapy

Services, Procedures and Devices Requiring Prior Authorization

(Last updated 10/22/2011)

-Abdominoplasty/other Lipectomies -Air Ambulance/Transport -Augmentation/Reduction Mammoplasty -Biofeedback -Blepharoplasty -Botox Injections -Brain Mapping, Grid Placement, Stereotaxis -Breast implant removal -Capsule endoscopy -Cochlear Implant -Cosmetic Eye Procedures -Cytogenetic Studies -Dermabrasion -Gastric Banding Procedures -Gastric Bypass and Gastrojejunostomy -Genetic Testing - Specific Genes/Diseases -Hearing Aids

-Intracranial Neurostimulators -LeForte Procedures -Mastectomy for Gynecomastia -Molecular Diagnostic Testing -Molecular Probes -Nerve Stimulators -Augmentation/Reduction Mammoplasty -Otoplasty for protruding ears -Orthotics/Prosthetics -Pain Management procedures -Psychological Testing (if > 4 hours) -Rhinoplasty, Rhinophyma -Rhytidectomy -Scar Abrasion/Chemical Peels -Septoplasty -Tattooing After Trauma or Cancer -Temporomandibular Joint (TMJ) procedures -Therapy - Physical PT, Occupational OT, Speech Language Pathology SLP, Cardiac Rehabilitation and Pulmonary Rehabilitation -Trigger Point Injections -Uvulopalatopharyngoplasty UPPP

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.

Medicare Part D Coverage Determination Form
Medicare Part D Redetermination Form
Medication Request Form - Partnership Medicaid

Prior Authorization Criteria iCare Medicare 2012
Prior Authorization Criteria iCare Partnership 2012
Step Therapy Criteria iCare Medicare 2012
Step Therapy Criteria iCare Partnership 2012

Referral Management

Referrals are required only for oral surgery and plastic/reconstructive surgery. The PCP must generate all referrals to specialists. Upon receipt of all required information, urgent referrals are processed within one (1) business day of receipt and two (2) business days for all other referrals.  Please complete the form below and send to:

• Fax: 414-231-1026
• Physician Referral Form

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