Services That Must be Pre-certified by the Innovation Care Partners: Medical Management Department:
All hospital admissions, except Observation Room > 24 hours stays, (Observation Stays greater than 72 hours must be authorized by ICP)
All hospital admissions for pregnant woman when there is a hospital stay that lasts longer than 48 hours (following a normal vaginal delivery) or 96 hours (following a cesarean section)
All elective surgical procedures to be performed in a hospital-based or free-standing outpatient ambulatory surgical facility (note: Ophthalmology authorizations will be for surgical procedure only not place of service) Except Colonoscopies
(Potentially) Cosmetic Procedures (ex: Breast Reduction & Reconstruction, Blepharoplasty, Strabismus)
DME purchases over $1,000
Prosthetics and orthotics over $2,000
MRI scan, MRA scans, Pet scan
Pain Management services (examples: epidurals or implantable infusion pumps)
Surgical treatment of TMJ conditions
Home health care- (including HonorHealth Home Care)
Home infusion therapy services
Specialty infusion/injectable medications which are covered under the Medical Benefits and not obtained through the Prescription Drug Benefits - See ICP List
Experimental or Investigational treatments or surgeries (including Clinical Trials)
Genetic Testing Lab Fees - (All genetics testing must have 3rd party pre - test Counseling documentation to obtain PA for labs)
Services at any post-acute facility (SNF, AIR, LTAC, etc)
Ambulance Services (non-emergent)
Hyperbaric Oxygen Therapy
Ventricular Assistive Device (VAD); Life Vests; Implantable Cardiac Defibrillators
Proton Beam Therapy
Speech Therapy
Adoptive Cell Therapy
Testosterone Hormone Therapy for Males
Outpatient Dialysis
Mental Health and Substance Abuse Services That Must be Pre-certified by Magellan Health:
Inpatient hospitalization (IP)
Residential hospitalization (RES)
Intensive outpatient (IOP)
Partial hospitalization (PHP)
Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation (TMS)
Psychological testing
Neuropsychological testing
Biofeedback
Applied behavioral analysis (ABA) therapy
Note: Pre-certification is not required for routine outpatient services
Magellan Behavioral Health Pre-Certification Telephone Number (800) 424-4138
Specialty infusion/injectable medications which are covered under the Medical Benefits and not obtained through the Prescription Drug Benefits. The following drugs require prior authorization:
Botulinum toxin type A and B: Botox®, Dysport®, Jeuveau®, Myobloc®, and Xeomin®
Medical Management Required 340-B Prior Authorization Medication Listing
Copaxone
Cosentyx
Enbrel
Gilenya
Humira
Hyqvia
Norditropin
Omnitrope
Simponi
Stelara
Xolair
The medications on the "Medical Management Required 340-B Prior Authorization Medication List" require prior authorization requests be submitted to ICP Prior Authorization Department AND HonorHealth Specialty Medication program, telephone #602-674-6222.
ICP Clinical Criteria and Guidelines
ICP makes Utilization Management (UM) decisions based only on appropriateness of care and service, including existence of coverage. The ICP UM Department uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions.
Below is the list of the clinical criteria used, but is not limited to:
Milliman Care Guidelines
UpToDate
Choosing Wisely
Micromedex
Government agencies such as FDA, CMS, CDC, PubMed
Clinical practice guidelines by National Associations when available
Innovation Care Partner’s Physician developed evidence-based guidelines
Medical Management Benefit Prescription Drug Criteria References
ICP uses nationally recognized clinical criteria to make evidence-based UM decisions. Criteria is available upon request by contacting (480) 400-0027.
Denials & Appeals
Following a request for service, you may receive notification of denial of service. Services can be denied related to your current health plan benefits and coverage, for not meeting medical necessity criteria, or for a service that is excluded from coverage under the provision of your plan.
Innovation Care Partners Medical Management Department discuss the necessary information related to the denial of services and advise you regarding the process should you wish to appeal this decision.
If you have received a notice of denial and you have questions or want to appeal the decision, please call:
Innovation Care Partners Medical Management Department