Prior Authorization Metrics
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Reports aggregated prior authorization metrics for medical items and services (excluding drugs) administered by Integrated Home Care Services to comply with the CMS Interoperability and Prior Authorization final rule; affects iCare members and providers submitting prior authorization requests.
No material clinical or coverage changes in this revision.
Prior Authorization Requirements
Prior authorization requirement notice
The document lists services that require prior authorization (link provided); it does not itself specify clinical coverage criteria.
Codes and Decision Timeframes
| No codes listed |
Provider Requirements and Reported Outcomes
Prior authorization list publication
The insurer publishes the list of medical items and services (excluding drugs) that require prior authorization on its prior authorization web page: http://www.icarehealthplan.org/Prior-Authorization.htm
Decision timeframes (current and Jan 1, 2026 rule)
Prior authorization decision timeframes are 72 hours for expedited (urgent) requests and 14 calendar days for standard (non-urgent) requests currently; beginning January 1, 2026, standard requests must be decided within 7 calendar days while expedited remains 72 hours.
- Current: Expedited 72 hours; Standard 14 calendar days
- Effective Jan 1, 2026: Expedited 72 hours; Standard 7 calendar days
Reported outcomes (counts & percentages for standard and expedited requests)
Reported outcomes include counts and percentages of approvals and denials, plus approvals after extension or appeal, presented separately for standard and expedited requests for the 2025 reporting period.
- Standard requests (n=4,424): 3,997 approved (90.35%), 427 denied (9.65%); 153 extended-review cases with 90 approved (58.82%) and 63 denied (41.18%); appeals: 4 approvals of 12 appeals (33.33%).
- Expedited requests (n=32): 24 approved (75.00%), 8 denied (25.00%); no extended-review cases reported.
- Time to decision: Standard mean/median 5 days; Expedited mean 7 hours, median 0 hours.
Request Type Definitions
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